LearningRadiology - Boerhaave's Syndrome

Ruptured Esophagus

• Nearly all esophageal perforations are caused by trauma

• Causes include:

> Iatrogenic–endoscopy (about 75% of the perforations in adults), dilatation procedures

> Stab wounds

> Occasionally, blunt compression of the chest

> Severe vomiting or straining

• Non-traumatic causes include neoplasm or caustic ingestion

• In infants, the most frequent site of rupture is the cervical esophagus 2° passage of tubes

Boerhaave's Syndrome

• Usually in men, although neonatal esophageal rupture occurs primarily in girls

• Associated with the clinical triad of vomiting, chest pain and subcutaneous/mediastinal emphysema

• In neonates, there is cyanosis and dyspnea associated with a right tension pneumothorax immediately after birth

• In Boerhaave’s, the inciting cause may be vomiting, straining, childbirth or a blunt blow to the abdomen or thorax

• Tears are vertically oriented, 1-4 cm in length

• Almost all (90%) occur along the left posterolateral wall of the distal esophagus

Photo shows extraluminal contrast
arising from left, posterolateral tear of esophagus

X-Ray

• Mediastinal emphysema

• Left pleural effusion

Photo shows mediastinal emphysema and
extraluminal contrast in pleural space on left

• Mediastinal widening

• Subcutaneous emphysema

• Nacleiro sign-a V-shaped radiolucency seen through the heart representing air in the left lower mediastinum that dissects under the left diaphragmatic pleura

• In neonatal rupture, pneumomediastinum is uncommon

• Method of study:

• First use a water-soluble contrast agent (Gastrografin, oral Hypaque)

• If no perforation is found, then barium may be used

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