A 40-year-old man develops severe retrosternal pain and vomiting after a heavy meal with alcohol. He is febrile, tachycardic, and has subcutaneous emphysema at the base of the neck. Chest X-ray shows left pleural effusion. Which is the most appropriate next investigation to confirm the diagnosis?

• A Barium swallow
• B Water-soluble contrast oesophagography ✓
• C Upper GI endoscopy
• D CT abdomen with oral contrast only

Explanation

The picture is spontaneous oesophageal rupture (Boerhaave syndrome). The diagnostic study is a contrast swallow using a water-soluble agent such as Gastrografin, which outlines the leak safely. Barium is avoided first because extravasated barium causes severe mediastinal inflammation and complicates surgery. Endoscopy risks worsening the tear by insufflation. Mackler triad of vomiting, chest pain and subcutaneous emphysema should immediately raise this diagnosis.

Reference: Sabiston Textbook of Surgery, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.