A 45-year-old alcoholic man vomits forcefully after a heavy meal and immediately develops severe retrosternal pain and dyspnoea. He is febrile, has subcutaneous emphysema at the root of the neck, and a chest radiograph shows left pleural effusion. Which is the most appropriate next investigation?

• A Rigid oesophagoscopy
• B Erect chest radiograph alone
• C Barium swallow
• D CT chest with oral water-soluble contrast ✓

Explanation

This is Boerhaave syndrome, spontaneous postemetic oesophageal rupture. CT with oral water-soluble contrast confirms the leak, defines its site and extent, and detects associated mediastinal contamination, so it is the investigation of choice. Endoscopy is avoided because insufflation can worsen the mediastinal soiling. Barium gives better leak definition but causes mediastinitis if it extravasates, so water-soluble contrast is preferred. An erect radiograph may show pneumomediastinum or effusion but cannot localise or confirm the perforation.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.