A 48-year-old alcoholic man develops sudden severe retrosternal pain and vomiting after a bout of retching. He is febrile, tachypnoeic, and has surgical emphysema at the root of the neck. Chest X-ray shows a left pleural effusion. Aspiration of the effusion reveals a pH of 6 with abundant amylase. What is the most likely diagnosis?

• A Acute pancreatitis with pancreaticopleural fistula
• B Mallory-Weiss tear
• C Perforated peptic ulcer
• D Boerhaave syndrome (spontaneous oesophageal rupture) ✓

Explanation

Forceful vomiting causing transmural rupture of the distal oesophagus is Boerhaave syndrome. The classic triad is vomiting, severe chest pain, and subcutaneous emphysema. Pleural fluid with low pH, high amylase, and undigested food particles confirms communication with the oesophagus. Mallory-Weiss tear kills the distractor because it is a mucosal tear at the gastro-oesophageal junction causing haematemesis, not full-thickness perforation with pleural contamination.

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

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Written and medically reviewed by the StethoPrep medical team.