A 40-year-old alcoholic man vomits after a binge and develops severe retrosternal pain radiating to the back, followed by breathlessness. He is febrile, tachycardic, and has surgical emphysema at the root of the neck. Chest X-ray shows a left pleural effusion. What is the most appropriate initial investigation to confirm the suspected diagnosis?
- A Barium swallow with full-strength barium as the first study
- B Contrast oesophagogram using water-soluble contrast ✓
- C Diagnostic upper GI endoscopy with insufflation
- D CT pulmonary angiography to exclude embolism
Correct answer: B. Contrast oesophagogram using water-soluble contrast
Explanation
The presentation is classic for spontaneous oesophageal rupture (Boerhaave syndrome): vomiting, severe chest pain, subcutaneous emphysema, and left effusion. B water-soluble contrast oesophagogram confirms extravasation safely. Full-strength barium is avoided first because extraluminal barium causes mediastinitis, though it may be used if water-soluble films are negative and suspicion persists. Endoscopy risks converting a small tear into a larger one by insufflation.
Reference: Bailey and Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.