A 45-year-old alcoholic man vomits after a heavy meal and develops sudden severe epigastric pain radiating to the back, followed by left chest pain and dyspnoea. He is febrile, tachypnoeic, and has subcutaneous emphysema at the root of the neck. Chest X-ray shows left pleural effusion with pneumomediastinum. Water-soluble contrast study confirms distal oesophageal perforation presenting 10 hours after onset. The best management is:

• A Left thoracotomy with primary repair of the perforation and pleural drainage ✓
• B Conservative management with broad-spectrum antibiotics, nil orally, and parenteral nutrition
• C Oesophageal stenting followed by elective oesophagectomy after six weeks
• D Percutaneous drainage of the pleural collection alone

Explanation

This is Boerhaave syndrome, a spontaneous full-thickness tear of the left posterolateral distal oesophagus after violent vomiting. In a fit patient presenting within 24 hours, the standard approach is early surgical exploration through a left thoracotomy with debridement, primary closure of the tear, reinforcement with a flap such as intercostal muscle or fundus, and drainage. Conservative therapy is reserved for small contained leaks in stable patients. Delayed presentation beyond 24 hours shifts many surgeons toward drainage plus diversion or stenting rather than simple primary repair.

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

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Written and medically reviewed by the StethoPrep medical team.