What is the appropriate diagnostic work‑up and emergent management for a patient with suspected oesophageal rupture (Boerhaave syndrome) presenting with sudden severe chest or upper‑abdominal pain after forceful vomiting?

Oesophageal Rupture (Boerhaave Syndrome): Diagnostic Work-Up and Emergent Management

Immediately obtain contrast-enhanced CT with CT esophagography in any patient presenting with severe chest or upper abdominal pain following forceful vomiting—this is the definitive diagnostic test with 92-100% sensitivity and must not be delayed. 1

Initial Diagnostic Approach

Immediate Actions (First 10-30 Minutes)

• Obtain a 12-lead ECG within 10 minutes to exclude myocardial infarction, but do not allow this to delay CT imaging when clinical suspicion is high. 1
• Order contrast-enhanced CT of the chest immediately after ECG—delaying CT to obtain other studies first directly compromises survival outcomes. 1
• Look for tachycardia (pulse >100 bpm) as the most critical vital sign abnormality that should raise immediate suspicion, along with systolic blood pressure <100 mmHg indicating shock. 1

Key Clinical Features to Recognize

• The classic Mackler's triad (chest pain, vomiting, subcutaneous emphysema) is rarely present—over 50% of cases have delayed diagnosis due to atypical presentation. 1
• Chest pain occurs in 70% of cases, fever in 50%, dyspnea in 25%, and subcutaneous emphysema in only 19%. 1
• Persistent rather than transient pain with rapid clinical deterioration suggests mediastinal contamination and developing sepsis. 1

Definitive Diagnostic Imaging

CT Findings That Confirm the Diagnosis

• CT will demonstrate pneumomediastinum, left-sided pneumothorax, left-sided pleural effusion, subcutaneous emphysema, free intra-abdominal air, extraluminal air and food residue, and can directly visualize the perforation site. 1
• Periesophageal fluid collections are present in 89-92% of esophageal perforations, and extraluminal air adjacent to the esophagus is present in 97% of perforations. 2
• Esophageal wall thickening with periesophageal infiltration occurs in 72-75% of cases, and focal wall defects or absence of post-contrast wall enhancement indicate transmural necrosis. 2

When to Use Additional Diagnostic Modalities

• Flexible endoscopy should be reserved for cases where CT findings are equivocal—it allows accurate diagnosis in >90% of cases and alters surgical management in 69% of patients. 3, 1
• If endoscopy is performed, use low-flow insufflation with CO2 rather than air to minimize mediastinal contamination by preventing enlargement of the perforation. 3
• Plain chest radiography alone is insufficient and may miss the diagnosis—reliance on X-ray should be avoided as it has up to 47% false-negative rate and misses 85% of pneumomediastinum cases. 2

Laboratory Studies

• Baseline laboratory studies including complete blood count, C-reactive protein, serum lactate, and basic metabolic panel are non-specific and must never postpone CT imaging. 1

Immediate Management After Diagnosis

Time-Critical Treatment Principles

• Time to diagnosis is the single most important predictor of survival—treatment initiated within 24 hours markedly improves outcomes, whereas delays beyond 24 hours raise mortality from a baseline of 10-20% to >50%. 1, 4
• Delayed surgical treatment beyond 24 hours does not affect mortality rates but significantly reduces the odds of successful primary esophageal repair. 3

Initial Therapeutic Measures

• Start broad-spectrum antibiotics covering both aerobic and anaerobic organisms immediately upon diagnosis. 1
• Place the patient on nil per os (NPO) status without delay. 1
• Initiate aggressive intravenous fluid resuscitation for hemodynamic support. 1
• Arrange urgent multidisciplinary consultation with gastrointestinal surgery, gastroenterology, and interventional radiology—this is now standardized practice given the complexity of decision-making regarding drainage, nutrition, stenting, and surgical intervention. 1

Surgical vs. Non-Operative Management Decision Algorithm

Indications for Immediate Surgical Treatment

• Patients should undergo immediate surgical treatment if they have hemodynamic instability, obvious non-contained extravasation of contrast material, or systemic signs of severe sepsis. 3
• Surgery should be undertaken as soon as possible—the literature consistently shows that delayed (>24 hours) surgical management results in increased morbidity and mortality rates. 3
• The tear is typically located on the left posterolateral wall of the lower third of the thoracic esophagus with a characteristically large wall defect (3-8 cm) causing contamination of the left thorax with air and digestive contents. 4

Criteria for Non-Operative Management

• Non-operative management can be offered only if the patient is hemodynamically stable, has contained perforation on imaging, and lacks systemic signs of severe sepsis. 3
• Non-operative management requires intense monitoring in an ICU setting with surgical expertise and interventional radiology skills available around the clock. 3
• Non-operative management includes NPO status, broad-spectrum antibiotics, endoscopic placement of nasogastric tube, early nutritional support (enteral feeding or total parenteral nutrition), and percutaneous radiological drainage of peri-esophageal collections. 3

Common Pitfalls to Avoid

• Do not rely on the presence of the complete Mackler's triad—it is rarely present and waiting for all three features delays diagnosis. 1
• Do not delay CT imaging to obtain contrast esophagography (barium or gastrografin swallow)—CT has replaced this as the first-line test because it provides comprehensive information on perforation location, extent, and associated complications. 1
• Do not perform routine endoscopy in all cases—endoscopy carries a risk of enlarging the perforation through insufflation and should be reserved for equivocal CT findings. 1
• Do not mistake this for myocardial infarction, pulmonary embolism, or aortic dissection—the history of forceful vomiting preceding chest pain is the key distinguishing feature. 5