A 55-year-old man presents with sudden onset severe chest pain and vomiting after a bout of heavy alcohol intake and retching. On examination, he is tachycardic, tachypneic, and has subcutaneous emphysema in the neck. Chest X-ray shows left-sided pleural effusion with pneumomediastinum. What is the most likely diagnosis?

• A Acute myocardial infarction
• B Acute pancreatitis
• C Perforated peptic ulcer
• D Spontaneous esophageal rupture (Boerhaave syndrome) ✓

Explanation

Boerhaave syndrome is a full-thickness esophageal perforation typically following forceful vomiting. The classic triad includes vomiting, chest pain, and subcutaneous emphysema. Pneumomediastinum and left pleural effusion on imaging confirm the diagnosis. It is a surgical emergency with high mortality if not treated within 24 hours. Perforated ulcer would present with pneumoperitoneum rather than pneumomediastinum. Myocardial infarction would not cause subcutaneous emphysema.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.