Oesophageal Rupture (Boerhaave)

A full-thickness tear of the oesophagus, classically after forceful vomiting or retching. It is rare, it is catastrophic, and mortality climbs steeply with every hour of delay — so the entire job is thinking of it in a patient who has been labelled…

Vomiting then chest pain — CT with contrast, surgeons now

The pathway

1 · The sequence is the clue

Vomiting or retching FIRST, then sudden severe chest or epigastric pain
That order is an important discriminator, not a diagnosis — in ACS and in pancreatitis the pain usually comes first
Pain is often severe, constant and out of proportion to the examination
Also after endoscopy, dilatation or TOE — an iatrogenic tear is commoner than a spontaneous one

2 · Examine for air where it should not be

Surgical emphysema in the neck or supraclavicular fossae — crackling under the fingers
Hamman's sign — a crunch over the praecordium with the heartbeat. Surgical emphysema after forceful vomiting strongly supports the diagnosis
Signs of a left pleural effusion
A sick, shocked, sweating patient with a soft abdomen

3 · Do not be reassured by the first-line tests

ECG may show non-specific changes and gets read as ACS
Amylase can be raised, which sends people down the pancreatitis route
CXR may be normal early, or show pneumomediastinum, a left effusion or a hydropneumothorax
A troponin rise does not exclude it

4 · CT chest and abdomen WITH contrast

Urgent contrast-enhanced CT chest and upper abdomen, on the local oesophageal-perforation protocol — it shows the leak, the air and the collection
Say the words "query oesophageal perforation" on the request, and agree the oral contrast protocol with radiology rather than assuming it
Do not send an unstable patient to CT alone
Endoscopy is a specialist decision, not a first step

5 · Resuscitate while you refer

Nil by mouth, large-bore access, fluids
Broad-spectrum antibiotics per local policy — the mediastinum is being soiled with oral flora
Antifungal therapy is NOT routine. Add it on risk assessment and microbiology advice — not for every perforation
IV proton pump inhibitor
Analgesia, and treat as sepsis if shocked
Do NOT pass a nasogastric tube blind — discuss placement with the surgical team

6 · Surgery and critical care, early

Upper GI or thoracic surgery early — this is their patient and the decision is time-critical. In a seriously unwell patient with strong suspicion, call before the CT is formally reported
Management ranges from stenting and drainage to primary repair, depending on the delay and the patient
Critical care alongside, because most of these patients need organ support
If your hospital has no upper GI service, start the transfer conversation tonight

Drugs

Drug	Dose	Route	Notes
Broad-spectrum antibiotic	Per local policy	IV	Mediastinitis from oral flora. Local policy wins; discuss with microbiology.
Antifungal therapy	NOT routine — risk-assessed, per microbiology	IV	Candida is a recognised mediastinal contaminant, but antifungal treatment is case- and risk-led rather than automatic. Discuss it; do not prescribe it reflexively.
Proton pump inhibitor	High dose IV, per local policy	IV	Reduces acid exposure at the tear.

When to escalate

Seriously unwell, or strong clinical suspicion — involve upper GI or thoracic surgery and critical care early, before formal CT reporting,Shock — critical care alongside, and treat as sepsis,No upper GI service on site — start the transfer conversation tonight, not in the morning,Patient labelled ACS or pancreatitis but the pain came AFTER vomiting — reopen the diagnosis

Reference: No single national guideline; management follows upper GI surgical practice and local mediastinitis policy. This pathway is about recognition and referral, which is the F1 contribution — the operative decisions belong to the surgical team.

This page is the reference half

The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.