A 48-year-old alcoholic retches violently after a binge and develops severe epigastric pain radiating to the back with vomiting. He is febrile, tachycardic, and has crepitus in the supraclavicular region. Chest X-ray shows a left pleural effusion and pneumomediastinum. Which statement about this condition is correct?

• A It is a mucosal tear confined to the oesophageal submucosa without perforation
• B Contrast swallow with water-soluble contrast confirms the full-thickness leak ✓
• C It typically involves the right posterolateral oesophageal wall
• D Conservative management is preferred even when presentation is within hours

Explanation

This is Boerhaave syndrome, a transmural postemetic rupture, usually of the left posterolateral distal oesophagus. Diagnosis is by contrast swallow using water-soluble contrast, or CT with oral contrast showing extraluminal gas and leak. Option A describes Mallory-Weiss syndrome, a mucosal tear presenting with bleeding rather than sepsis. Early presentation within 24 hours favours primary surgical repair over conservative management, so option D is wrong despite being commonly believed.

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

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Written and medically reviewed by the StethoPrep medical team.