Esophageal perforation - Boerhaave syndrome

In this patient with no known risk factors for oesophageal perforation (except inflammatory bowel disease and recent surgery), this would be considered a spontaneous oesophageal perforation, also known as Boerhaave syndrome.

The classic presentation for Boerhaave syndrome is a history of severe vomiting (as seen with the index case, named by Dr. Boerhaave). The classic radiographic presentation is pneumomediastinum and a left-sided pleural effusion. In this case, the pleural effusion was predominantly right-sided.

An important point to remember is that one should always begin the study with water-soluble contrast (e.g. Gastrografin). If a perforation is found, then the study can be stopped. Barium is not typically used in this setting due to concern about possible mediastinitis and itsbarium's long term effects in the pleural space. A controversial scenario occurs there is a strong concern for esophageal perforation and no leak seen with Gastrografin. Some advocate that high density barium is more likely to reveal a subtle leak in this setting, but the risk of barium in the pleural space has to be carefully weighed against missing a small subtle esophageal perforation, which could be fatal if not diagnosed. Caution, judgment, and the level of clinical suspicion must come into play if considering this approach.

On the scout image, a thin crescent of gas outlines the bottom of the heart, compatible with pneumomediastinum. Bilateral chest tubes.

With the ingestion of Gastrografin, a right-sided oesophageal leak into the pleural space quickly occurs. The leak crosses over slightly into the left pleural space and extends a little into the retrocrural/retroperitoneal space as well.

As long as the patient is not an aspiration risk, the standard type of contrast used in this setting is *water-soluble* per oral contrast (e.g. Gastrografin). Some centercenters use oral Omnipaque or Isovue; although this is a these are weaker agentagents for contrast, and a small leak may not be seen, it significantly lowers the risk to the patient if aspirated. Barium is not often used first because of the concern that it could cause mediastinitis and/or adhesions in the pleural space.