A 46-year-old man retches violently after heavy alcohol intake and then develops sudden severe epigastric pain radiating to the back, followed by fever and breathlessness. He has surgical emphysema at the root of the neck and a crackling sound over the precordium. Chest radiograph shows a left pleural effusion. Which investigation will best establish the diagnosis?

• A Barium swallow with full-strength barium to outline the mucosa
• B Upper gastrointestinal endoscopy with insufflation to visualise the tear directly
• C Water-soluble contrast swallow demonstrating extravasation from the lower oesophagus ✓
• D Contrast-enhanced CT of the chest showing aortic dissection flap

Explanation

The Mackler triad of vomiting, severe lower chest pain and subcutaneous emphysema with a left effusion points to spontaneous rupture of the oesophagus (Boerhaave syndrome). Diagnosis is made with a water-soluble contrast swallow showing extravasation; water-soluble agent is used first because barium outside the oesophagus provokes mediastinitis. Endoscopy risks worsening the tear by insufflation, and CT supports but does not demonstrate the leak as definitively as the contrast swallow.

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.