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Oesophageal perforation (including Boerhaave's)
Oesophageal perforation is life-threatening and every hour of delay raises mortality; the most common cause is an endoscopic procedure, and treatment depends on the time elapsed, the extent of the leak and the patient's condition — from conservative care to surgery.
Why it matters in the exam
The classic picture is Boerhaave's: a man after forceful vomiting (sometimes after a meal and alcohol) with severe chest pain and air under the skin of the neck. Questions check that you can tell it apart from Mallory–Weiss — a mucosal tear only, presenting with bloody vomiting, which almost always settles by itself — and from myocardial infarction, aortic dissection and pancreatitis, all of which can look similar at first.
Candidates are also asked about diagnosis and treatment: CT with oral contrast, or a water-soluble contrast swallow, shows the leak; the chest X-ray shows mediastinal air and a left-sided effusion. Basic treatment is nil by mouth, broad antibiotics and an antifungal, PPI and drainage; a small contained perforation diagnosed early in a stable patient is treated conservatively or with an endoscopic stent, while a perforation open into the chest with sepsis needs surgery — reinforced primary repair and drainage. Pleural fluid with high amylase and low pH strengthens the suspicion.
Key points
- Most common cause: an endoscopic procedure; Boerhaave's after forceful vomiting.
- Diagnosis: CT with oral contrast or a water-soluble contrast swallow.
- Basic treatment: nil by mouth, antibiotics and an antifungal, PPI and drainage.
- Contained and stable — conservative or endoscopic; free leak and sepsis — surgery.
- Mallory–Weiss — a mucosal tear that bleeds, usually settles by itself.
Summary table
| Situation | Finding | Treatment |
|---|---|---|
| Iatrogenic perforation (most common) | Pain, fever or surgical emphysema after endoscopy or dilation | Rapid CT diagnosis; small and contained — conservative care or endoscopic closure |
| Boerhaave's | Forceful vomiting, chest pain, surgical emphysema; usually the left side of the lower oesophagus | Contrast CT; early surgery for a free leak |
| Mallory–Weiss | Bloody vomiting after repeated vomiting; mucosal tear only | Most bleeds stop by themselves; endoscopic treatment for active bleeding |
| Contained perforation in a stable patient | Small leak that drains back into the oesophagus | Nil by mouth, antibiotics, antifungal, PPI and feeding; sometimes a stent |
| Uncontained perforation with sepsis | Fluid and air in the chest, shock | Surgery: reinforced primary repair, drainage and washout |
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Sources
- WSES guidelines: Esophageal emergencies, 2019 — Perforation, Boerhaave syndrome and caustic injury
- Sabiston Textbook of Surgery, 21st edition (2022) — Esophagus
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Thoracic Trauma
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.