Spontaneous esophageal rupture: Boerhaave's syndrome

Spontaneous esophageal rupture (SER) is the most frequently fatal gastrointestinal perforation. Vomiting is the usual but not the sole etiology of SER. Rapid rises in esophageal pressure, discoordination of the vomiting reflex, and underlying esophageal disease contribute to its occurrence. The classic Meckler's triad of symptoms includes vomiting, lower chest pain, and cervical subcutaneous emphysema following overindulgence in food or alcohol, but is observed in only half of the cases. The most common chest radiograph findings in SER are pleural effusion (91%) and pneumothorax (80%). The initial sign on a plain film may be pneumomediastinum or subcutaneous emphysema. Up to 12% of patients with SER may have a normal chest radiograph. Contrast-enhanced esophageal radiography is diagnostic in 75% to 85% of cases. If there is no extravasation of contrast but clinical suspicion remains high, the study should be repeated. The pleural effusion is characterized by a high amylase concentration and low pH. Pleural fluid pH below 6 is highly suggestive of SER. The appearance of food particles in pleural fluid is diagnostic of SER. Survival rate following early surgical intervention is 70%, and operative mortality is 10% to 30%. A delay of surgical treatment greater than 24 hours is associated with a 64% mortality. Hence, early recognition and operation are critical. The correct diagnosis of SER is usually not made within the first 12 hours after occurrence. A high index of suspicion is crucial since in most instances a chest radiograph and esophagogram can provide the diagnosis. The presence of shock, severe debilitation, and a moribund state are urgent indications rather than contraindications to surgical treatment.