A 62-year-old man develops severe retrosternal pain and vomiting after a heavy meal with alcohol. He is febrile, tachypnoeic, and has crepitus in the suprasternal notch. Chest X-ray shows a left pleural effusion. Which is the single best initial investigation to confirm the suspected diagnosis?

• A Water-soluble contrast oesophagography ✓
• B Barium swallow
• C CT thorax with oral barium contrast
• D Flexible oesophagoscopy

Explanation

The presentation is Boerhaave syndrome (spontaneous transmural oesophageal rupture), typically postemetic with Mackler triad of vomiting, chest pain and subcutaneous emphysema. Water-soluble contrast oesophagography is the standard first study because extravasation confirms the leak while avoiding mediastinal soiling by barium. Barium gives better sensitivity but is avoided first-line for this reason. Endoscopy risks worsening the tear by insufflation.

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.