Boerhaave syndrome is one of those GI emergencies that shows up on exams because it’s dramatic, deadly, and testable from multiple angles (path, imaging, management, complications). If you can recognize the “post‑vomiting + chest pain” story and know what to do next, you’ll pick up easy points—and potentially save a life in real life.
What is Boerhaave Syndrome?
Boerhaave syndrome = spontaneous, transmural esophageal rupture due to a sudden spike in intraesophageal pressure, classically after forceful vomiting/retching.
- Key distinction (very testable):
- Boerhaave: full-thickness (transmural) perforation → mediastinitis, sepsis
- Mallory-Weiss: mucosal tear at GE junction → painful hematemesis, no perforation
Pathophysiology (the “why it happens” Step 1 loves)
Mechanism
- Forceful emesis against a closed glottis (or uncoordinated cricopharyngeus relaxation) causes a rapid rise in intraesophageal pressure
- Leads to full-thickness tear, most commonly:
- Left posterolateral distal esophagus, a few cm above the GE junction
What happens next
A transmural tear allows:
- Air → pneumomediastinum, subcutaneous emphysema
- Gastric contents + bacteria → chemical + bacterial mediastinitis
- Pleural contamination (often left-sided) → pleural effusion, empyema, pneumothorax
Clinical consequence: rapid progression to sepsis and shock if not treated quickly.
Classic Clinical Presentation (and common traps)
The “textbook” triad (Mackler triad)
- Vomiting
- Chest pain
- Subcutaneous emphysema
In reality, patients may not have all three—so don’t anchor too hard.
Symptoms and signs to know
- Severe chest pain after vomiting (can radiate to back/shoulder)
- Dyspnea, tachypnea
- Fever (often later)
- Crepitus in neck/chest from subcutaneous emphysema
- Tachycardia, hypotension as mediastinitis/sepsis develops
High-yield associations / risk contexts
- Alcohol binge + repeated retching
- Bulimia
- Any cause of severe vomiting (GI obstruction, gastroenteritis, pregnancy-related hyperemesis)
Important differential diagnoses (what NBME wants you to separate)
| Condition | Key trigger | Key symptom(s) | Key finding | Key complication |
|---|---|---|---|---|
| Boerhaave | Forceful vomiting | Severe chest pain, dyspnea | Pneumomediastinum, contrast leak | Mediastinitis, sepsis |
| Mallory-Weiss | Retching | Hematemesis | Mucosal laceration at GE junction | Usually self-limited bleeding |
| MI | Exertion/risk factors | Chest pressure | ECG/troponins | Arrhythmia, shock |
| Aortic dissection | HTN, connective tissue dz | “Tearing” back pain | Widened mediastinum, CTA | Tamponade, rupture |
| Pancreatitis | Alcohol, gallstones | Epigastric pain → back | ↑Lipase | Necrosis, ARDS |
Diagnosis (the Step-friendly algorithm)
First imaging clue: Chest X-ray (often first test)
Possible findings:
- Pneumomediastinum
- Left pleural effusion
- Pneumothorax
- Subcutaneous emphysema
- Sometimes mediastinal widening
Not every patient has a slam-dunk CXR—normal early imaging does not fully exclude it.
Confirmatory testing (high yield)
Water-soluble contrast esophagram (e.g., Gastrografin) is a classic confirmatory study:
- Shows contrast extravasation from esophagus into mediastinum/pleural space
CT chest with water-soluble oral contrast is increasingly common:
- Helpful for unstable patients or when you want to define extent/complications
- Can show mediastinal air, fluid collections, pleural effusion, and leak
A critical pitfall: avoid the wrong contrast
- Avoid barium first if perforation is suspected (barium in mediastinum is inflammatory and hard to clear)
- If water-soluble study is negative but suspicion remains high, some protocols escalate (institution-dependent) — exam questions typically stop at “water-soluble contrast study.”
What about endoscopy?
- Not first-line for diagnosis in suspected perforation because it can worsen the tear (insufflation)
- Might be used selectively for therapy in contained leaks, depending on stability/expertise
Treatment (what you do immediately vs definitively)
Boerhaave is a surgical emergency.
Immediate management (before anything fancy)
- NPO
- IV fluids (resuscitate)
- Broad-spectrum IV antibiotics covering oral flora + anaerobes
- Typical coverage includes gram positives, gram negatives, anaerobes
- IV PPI (often given in practice)
- Pain control
- Early surgical consult (do not delay)
Definitive management (depends on stability + containment + timing)
Management is nuanced, but exams generally frame it like this:
-
Unstable patient, free perforation, sepsis, large leak, contamination:
- Urgent surgical repair + mediastinal/pleural drainage
-
Stable, contained perforation, minimal contamination, early presentation:
- Possible nonoperative approach in select cases (NPO, antibiotics, close monitoring)
- Endoscopic approaches (e.g., stent/clips) may be used in some settings
Timing matters (why “early recognition” is always emphasized)
- Outcomes worsen dramatically as time to definitive control increases (mediastinitis → sepsis → shock)
Complications (favorite exam follow-ups)
- Mediastinitis (big one): fever, leukocytosis, toxicity, chest pain worsening
- Sepsis / septic shock
- Empyema (often left-sided), pleural effusion
- Pneumothorax
- ARDS (from severe systemic inflammation)
High-Yield “Buzz Phrases” & Memory Hooks
Buzz phrases
- “Severe chest pain after forceful vomiting”
- “Subcutaneous emphysema/crepitus”
- “Pneumomediastinum”
- “Left pleural effusion after emesis”
- “Contrast extravasation on water-soluble esophagram”
Quick memory anchors
- Boerhaave = Burst (full-thickness)
- Mallory-Weiss = Mucosal tear with Wet blood (hematemesis)
First Aid Cross-References (where this lives conceptually)
You’ll see Boerhaave tested under esophageal pathology and in the differential of chest pain after vomiting:
- Esophageal disorders (rupture vs tear; complications)
- GI bleeding (to contrast with Mallory-Weiss)
- Mediastinitis/pneumomediastinum as imaging findings
- Complications of vomiting/alcohol use (clinical associations)
How to use First Aid efficiently here: when you review esophageal tears, force yourself to make a two-row table in your notes (Boerhaave vs Mallory-Weiss) and attach imaging + management—that’s where question writers differentiate.
Rapid Review (what to recall in 15 seconds)
- Definition: Spontaneous transmural esophageal rupture after vomiting
- Presentation: Vomiting + severe chest pain ± subQ emphysema; can rapidly become septic
- Diagnosis: CXR may show pneumomediastinum/left effusion; confirm with water-soluble contrast esophagram (or CT with oral contrast)
- Treatment: NPO + IV fluids + broad-spectrum antibiotics + urgent surgical consult; operative repair if unstable/free perforation
- Complication: Mediastinitis (life-threatening)