A 40-year-old man presents with severe retrosternal chest pain and subcutaneous emphysema after an episode of forceful vomiting following binge drinking. Chest X-ray shows left pleural effusion and pneumomediastinum. What is the most likely diagnosis?
- A Spontaneous esophageal rupture (Boerhaave syndrome) ✓
- B Mallory-Weiss tear
- C Perforated peptic ulcer
- D Acute mediastinitis of dental origin
Correct answer: A. Spontaneous esophageal rupture (Boerhaave syndrome)
Explanation
Boerhaave syndrome is a transmural esophageal rupture typically caused by forceful vomiting, most commonly affecting the left posterolateral distal esophagus. It presents with Mackler's triad: vomiting, chest pain, and subcutaneous emphysema. Mallory-Weiss is a mucosal tear without transmural perforation and does not cause pneumomediastinum. Perforated ulcer would show pneumoperitoneum, not pneumomediastinum.
Reference: Bailey and Love's Short Practice of Surgery, 28th ed.
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