Esophageal Rupture (Boerhaave Syndrome)

What happens in esophageal rupture

The esophagus runs through the chest (mediastinum), behind the heart and between the lungs. In Boerhaave syndrome, the stomach contracts violently during vomiting while the upper esophageal sphincter stays closed. Pressure inside the lower esophagus rises sharply and bursts the wall, most often on the lower left side just above the stomach.

Stomach contents then spill into the chest, causing mediastinitis (infection of the central chest), fluid and air around the lung, and sepsis. Without treatment, the death rate is very high. Treatment within 24 hours greatly improves survival.

A partial, superficial tear of the esophageal lining after vomiting is a different condition, a Mallory-Weiss tear. It causes bleeding but not leakage, and usually heals on its own.

Causes

Risk factors for Boerhaave syndrome include heavy alcohol use, binge eating, eating disorders with purging, and existing esophageal disease such as reflux and esophagitis. For a broader look at all causes of a tear, see esophageal perforation.

Symptoms

• sudden, severe chest pain, often behind the breastbone or in the upper belly, sometimes spreading to the back or left shoulder
• pain that started after vomiting or retching
• pain when swallowing, or inability to swallow
• shortness of breath and fast breathing
• crackling under the skin of the neck or chest (subcutaneous emphysema)
• fever, fast heart rate and sweating as infection develops
• low blood pressure and confusion in sepsis
• vomiting blood (less common)

The classic Mackler triad is vomiting, lower chest pain and air under the skin, but all three are present in only a minority of patients.

Why it is often missed

Esophageal rupture is rare and its symptoms overlap with more common emergencies, including heart attack, aortic dissection, perforated ulcer, pancreatitis, pneumonia and collapsed lung. A history of vomiting before the pain began is an important clue.

Diagnosis

• CT scan of the chest and abdomen with oral contrast: shows air or fluid around the esophagus, contrast leaking out, and pleural effusions. It is the preferred test.
• Contrast swallow study: water-soluble contrast first, to show the leak.
• Chest X-ray: may show air in the mediastinum, a collapsed lung, or fluid around the lung, especially on the left.
• Endoscopy: used carefully in selected cases, often combined with treatment.
• Blood tests: infection markers, kidney function and lactate. Fluid drained from the chest may contain food particles or high amylase.

Treatment

Treatment is urgent and usually in an intensive care unit.

Initial care

• nothing by mouth
• IV fluids
• broad-spectrum IV antibiotics and often antifungal medicine
• acid-suppressing medicine
• chest tube drainage of fluid and air
• nutrition through a feeding tube placed beyond the tear, or by vein

Repairing the tear

• Surgery: direct repair of the tear and cleaning of the chest cavity, often through a chest incision or by keyhole surgery. Best results are within 24 hours.
• Endoscopic stents or clips: covered stents can seal the leak, often combined with drainage, in suitable patients.
• Endoscopic vacuum therapy: a sponge on suction placed into the defect to promote healing, used in specialist centers.
• Non-surgical management: for small, contained leaks in stable patients.
• Esophagectomy: removal of the esophagus, reserved for extensive damage or underlying cancer.

Complications

• mediastinitis and sepsis
• empyema (pus around the lung)
• respiratory failure
• persistent leak or fistula
• esophageal narrowing later

Outlook

Esophageal rupture remains a high-risk condition. Mortality is much lower with early diagnosis and treatment, and rises steeply with delays beyond 24 to 48 hours. Survivors usually recover swallowing function, though some need dilation for narrowing. Treating alcohol use disorder or an eating disorder helps prevent recurrence.

Frequently asked questions

What is Boerhaave syndrome?

Boerhaave syndrome is a spontaneous full-thickness tear of the esophagus caused by forceful vomiting or retching. It usually affects the lower left esophagus and allows stomach contents to leak into the chest. It is a medical emergency that needs immediate treatment.

What are the symptoms of a ruptured esophagus?

Typical symptoms are sudden severe chest or upper belly pain, often after vomiting, pain or difficulty swallowing, shortness of breath, crackling under the skin of the neck or chest, fever and a fast heart rate. Symptoms worsen quickly as infection spreads.

What causes the esophagus to rupture?

Most perforations are caused by medical procedures such as endoscopy. Spontaneous rupture follows forceful vomiting, often linked to heavy alcohol use or binge eating. Swallowed sharp objects or button batteries, chest trauma, caustic chemicals and esophageal cancer are other causes.

Is a torn esophagus the same as a Mallory-Weiss tear?

No. A Mallory-Weiss tear is a partial tear of the lining that causes bleeding after vomiting and usually heals on its own. An esophageal rupture goes through the full wall and leaks into the chest, which is far more dangerous and needs emergency treatment.

Can you survive an esophageal rupture?

Yes, especially with fast treatment. Survival is much better when the rupture is diagnosed and treated within 24 hours with antibiotics, drainage and repair. Delays increase the risk of severe infection and death, so sudden chest pain after vomiting needs emergency care.