Vomiting, chest pain and surgical emphysema: CT shows pneumomediastinum and a left-sided effusion centred on the distal oesophagus, and oral contrast shows the leak — the site and the side decide the thoracic surgery.
Orient first
- Boerhaave rupture is usually in the left posterolateral wall of the distal oesophagus, just above the diaphragm.
- Iatrogenic perforation (endoscopy, dilatation) is now more common than spontaneous.
- Mediastinitis follows within hours; delay beyond 24 h increases mortality.
Acquire the study
- CT chest and upper abdomen with IV contrast and 50–100 ml water-soluble oral contrast just before scanning; lung window.
The manoeuvre
- Lung window: pneumomediastinum centred on the distal oesophagus; surgical emphysema in the neck.
- Oral contrast extravasating into the mediastinum or pleural space — the site in cm above the gastro-oesophageal junction.
- Left pleural effusion or hydropneumothorax; mediastinal fluid collections.
- Oesophageal wall thickening and a wall defect.
What confirms it
- Extraluminal oral contrast or periesophageal gas and fluid with a wall defect after vomiting or instrumentation.
What licenses you to exclude it
- CT with oral contrast showing no extraluminal gas, fluid or contrast around the oesophagus excludes perforation.
The classic misread
- Calling pneumomediastinum from asthma or cocaine inhalation Boerhaave without periesophageal fluid or leak.