What is the most common location for an esophageal rupture or perforation in a patient with severe pleuritic chest pain radiating to the back after forceful vomiting?

Most Common Location of Esophageal Rupture in Boerhaave Syndrome

The most common location for spontaneous esophageal perforation (Boerhaave syndrome) is the distal posterolateral esophagus on the left side.

Anatomical Location

The tear is typically located on the left border of the lower third of the thoracic esophagus, and the wall defect is characteristically large (3–8 cm) 1. This specific location occurs in approximately 90% of cases of spontaneous esophageal rupture 2.

• The perforation occurs at the left posterolateral wall of the distal esophagus 3
• This anatomical predilection explains why most patients present with left-sided pleural effusions rather than right-sided 2
• Less than 10% of patients have bilateral effusions, and even fewer present with isolated right-sided effusions 2

Mechanism and Pathophysiology

The location is determined by the underlying mechanism:

• Boerhaave syndrome results from an abrupt increase in esophageal pressure following forceful vomiting in the absence of relaxation of the upper esophageal sphincter 1
• This barotrauma preferentially affects the distal esophagus where the wall is anatomically weaker on the posterolateral aspect 1, 3
• The condition accounts for approximately 15% of all esophageal perforations 1, 3

Clinical Significance

Understanding this location is critical for diagnosis and management:

• The left-sided location typically causes contamination of the left thorax with air and digestive contents 1
• This differs significantly from iatrogenic perforations (which account for 60% of all esophageal perforations) that can occur at any level depending on the procedure 1, 3
• Mortality ranges between 10-20%, with delay in treatment being the most important survival predictor 1

Key Distinguishing Features

Boerhaave syndrome differs from other esophageal perforations in several important ways 1:

• The tear is usually multiple small partial tears or tissue plane dissections rather than a single massive tear 1
• There is limited extravasation (mostly air and liquid) compared to the massive contamination seen in other causes 1
• Surgery is required in only about 30% of cases, with most resolving with conservative management 1

Answer: Distal posterolateral esophagus (specifically the left posterolateral wall of the lower third of the thoracic esophagus).