Ruling Out Boerhaave Syndrome in the Emergency Department
Contrast-enhanced CT with CT esophagography is the definitive imaging study to rule out Boerhaave syndrome and should be performed immediately in any patient with severe retching/vomiting followed by chest pain, as this modality has 92-100% sensitivity for detecting esophageal perforation. 1, 2
Clinical Recognition: High-Risk Features
The key to ruling out Boerhaave syndrome is maintaining a high index of suspicion, as over 50% of cases have delayed diagnosis due to atypical presentation. 2, 3 Look specifically for:
- Tachycardia (pulse >100 bpm) - the most critical vital sign abnormality that should raise immediate suspicion 2
- Persistent rather than transient chest pain following vomiting episodes 2
- Subcutaneous emphysema of the neck or chest (present in only 19% of cases) 2, 4
- Shock (systolic BP <100 mmHg with tachycardia) indicating rapid deterioration 2
Note that the classic Mackler's triad (chest pain, vomiting, subcutaneous emphysema) is rarely present in its entirety, making diagnosis challenging. 5, 6
Immediate Diagnostic Algorithm
Step 1: Obtain ECG Within 10 Minutes
- Rule out myocardial infarction, as Boerhaave syndrome commonly mimics cardiac emergencies 5, 6
- This should not delay imaging if clinical suspicion is high 1
Step 2: Order Contrast-Enhanced CT Immediately
Contrast-enhanced CT with CT esophagography is the gold standard with 92-100% sensitivity and should be performed without delay. 1, 2, 3 This imaging will reveal:
- Pneumomediastinum (air in the mediastinum) 2, 3
- Pneumothorax (typically left-sided) 2, 3
- Pleural effusion (usually left-sided) 2, 3
- Subcutaneous emphysema 2, 3
- Air under the diaphragm 2, 3
- Extraluminal air and food residue 5
- Direct visualization of the perforation site and extent 1, 2
Step 3: Supportive Laboratory Studies
While not diagnostic, obtain: 1
- Complete blood count (CBC)
- C-reactive protein (CRP)
- Serum lactate (elevated suggests developing sepsis)
- Basic metabolic panel
These laboratory studies are non-specific and should never delay CT imaging. 1
What NOT to Do
- Do not order contrast esophagography (barium or gastrografin swallow) as a first-line test - CT has replaced this modality as it provides more comprehensive information about perforation location, extent, and associated complications 1
- Do not wait for endoscopy - diagnostic endoscopy should only be performed if CT findings are equivocal, as there is risk of enlarging the perforation 1
- Do not rely on chest X-ray alone - while plain radiographs may show indirect signs (pleural effusion, pneumomediastinum, subcutaneous emphysema), they can miss the diagnosis 1
Critical Time-Dependent Considerations
Time to diagnosis is the single most important survival predictor - treatment within 24 hours significantly improves outcomes, while delay beyond 24 hours causes exponential increases in mortality from a baseline of 10-20% to over 50%. 1, 2, 3, 4 This makes rapid diagnostic workup essential.
When Boerhaave is Confirmed
If CT confirms esophageal perforation, immediately initiate: 1
- Broad-spectrum antibiotics covering aerobic and anaerobic bacteria
- NPO (nil per os) status
- Intravenous fluid resuscitation
- Urgent multidisciplinary consultation (gastrointestinal surgeon, gastroenterologist, interventional radiologist) 2, 3
Common Diagnostic Pitfalls
- Mistaking symptoms for myocardial infarction, pulmonary embolism, or aortic dissection - these are the most common misdiagnoses 5, 6, 7
- Dismissing the diagnosis because subcutaneous emphysema is absent - this finding is present in less than 20% of cases 2, 4
- Waiting for "classic" presentation - atypical presentations are the norm, not the exception 2, 3, 6
- Delaying CT to obtain other studies first - CT should be the immediate next step after ECG in suspected cases 1, 2