Boerhaave Syndrome

Michael P. Federle, MD, FACR

Key Facts

Imaging

Sudden increase in intraluminal pressure leads to full thickness esophageal perforation
- Usually from left side of distal thoracic esophagus
Chest film
- Left side pleural effusion or hydropneumothorax
- Radiolucent streaks of gas along aorta or in neck
Esophagography with nonionic, water-soluble contrast agent
- Shows extravasation of ingested or injected (through NG tube) contrast medium
- From left side of esophagus, just above GEJ
CT
- Extraluminal gas &/or oral contrast medium in lower mediastinum ± upper abdomen
Protocol advice
- Plain chest radiograph; helical CECT with oral contrast
- Esophagography with nonionic water-soluble contrast agent
- If initial study with water-soluble contrast medium fails to show leak; examination must be repeated immediately with barium to detect subtle leaks

Clinical Issues

Accounts for 15% of total esophageal perforation cases
Prognosis for large perforation
- After 24 hours without treatment: Mortality = 70%
- After immediate surgical drainage: Good
Treatment
- Drains in esophagus, mediastinum, pleural space, ± abdomen

(Left) Graphic shows a vertically oriented laceration

of the distal esophagus, just above the hiatus and GE junction. (Right) Film from an esophagram, following injection of water-soluble contrast medium through a nasogastric tube, demonstrates a leak of contrast medium