Timely implementation of evidence-based treatment
- Boerhaave syndrome, a rare but life-threatening spontaneous rupture of the esophagus, requires prompt recognition and treatment.
- Understanding the condition’s presentation and diagnostic challenges can help improve patient outcomes.
James Thompson*, a 27-year-old man with no significant past medical history, received a diagnosis of viral gastroenteritis 2 days ago and has had persistent vomiting despite treatment with promethazine 25 mg oral tablets. He arrived at the ED with sudden onset of sharp chest pain.
History and assessment
In the ED, Mr. Thompson describes his chest pain to Mark, the triage nurse, as 10/10, sharp, and radiating to his back. During Mark’s assessment, Mr. Thompson persistently retches; he appears pale and diaphoretic, and is in acute distress. Vital signs are temperature 37.3 °C (99.1 °F), HR 132 bpm, RR 24 breaths per minute, BP 108/52 mmHg, and O2 95% on room air. Mark notes subcutaneous emphysema in the upper chest bilaterally. Concerned about a possible esophageal tear, Mark transports Mr. Thompson to a treatment area and notifies the ED physician.
Taking action
Mark places Mr. Thompson on continuous cardiac and pulse oximetry monitoring, initiates NPO status, and inserts two 18-g I.V. catheters. The ED physician’s assessment reveals subcutaneous emphysema and a positive Hamman’s sign (mediastinal crackling auscultated in the left lateral decubitus position). She orders a STAT CBC, CMP, two sets of blood cultures, and lactic acid. The CBC reveals leukocytosis. A portable chest x-ray shows pneumomediastinum; a chest and abdomen CT with contrast shows esophageal wall thickening, mediastinal widening, and periesophageal fluid consistent with thoracic esophageal perforation.
The ED physician orders a 0.9% normal saline bolus and piperacillin-tazobactam 3.375 g I.V. to cover aerobes and anaerobes in the setting of mediastinal contamination. The cardiothoracic surgery consultant recommends primary surgical repair.
Outcome
After surgery, Mr. Thompson is admitted to the ICU for monitoring. He receives enteral feedings via a jejunostomy placed during surgery.
He continues to receive piperacillin-tazobactam 3.375 g I.V. every 6 hours and maintenance I.V. fluids. Pantoprazole 40 mg I.V. twice daily reduces gastric acid production. On postoperative Day 3, Mr. Thompson is transferred to the general surgery unit. On Day 10, a contrast chest CT confirms no esophageal leak. His diet is gradually advanced, and he’s discharged home with close primary care and surgery follow-up.
Education and follow-up
Boerhaave syndrome, spontaneous esophageal rupture caused by sudden increase in intraesophageal and negative intrathoracic pressure, is primarily caused by retching, straining, or vomiting.
Patients with Boerhaave syndrome frequently present with chest pain that radiates to the back, chest wall crepitus, dyspnea, and Hamman’s sign. Mackler’s Triad (vomiting, chest pain, subcutaneous emphysema) occurs only in 20% to 40% of patients. Up to 70% of patients present with systemic manifestations, including tachycardia and leukocytosis. (See Esophageal rupture: Incidence, mortality, complications, differential diagnosis)
Esophageal rupture: Incidence, mortality, complications, differential diagnosis
With an incidence of only three per 1,000,000 individuals, esophageal ruptures can occur in the cervical, intrathoracic, and intra-abdominal regions. Intra-thoracic perforations are most common due to the length of the esophagus.
Mortality rates of esophageal perforations range from 10% to 50%.
Complications include sepsis, bacteremia, mediastinitis, pneumonia, and pleural effusions.
Mallory-Weiss tears, superficial tears in the esophageal mucosal layer at the junction of the esophagus and stomach, occur after a sudden rise in intrabdominal pressure. Treatment is primarily supportive.
Contrast CT chest and abdomen scans are sensitive and specific for diagnosing esophageal rupture and evaluating surrounding structures. Initial treatment includes NPO status, I.V. fluids, and antibiotic therapy. Ruptures can be managed surgically or endoscopically; clinically stable patients can be managed nonoperatively. Surgical and endoscopic treatment options include primary closure, endoscopic stenting, and endoscopic vacuum therapy.
Positive outcomes require timely identification, diagnosis, and definitive treatment. Mark’s triage assessment facilitated prompt implementation of an evidence-based treatment plan.
*Names are fictitious
Aaron Sebach is dean and professor in the College of Nursing and Health Sciences Health Professions and Natural Sciences at Wilmington University in New Castle, Delaware, and nurse practitioner at TidalHealth in Salisbury, Maryland.
American Nurse Journal. 2026; 21(9). Doi: 10.51256/ANJ092664
References
Kanyongo R. Esophageal perforation. The American Association for Thoracic Surgery. aats.org/tsra-primer-esophageal-perforation
Kassem MM, Wallen JM. Esophageal perforation and tears. StatPearls. August 19, 2024. ncbi.nlm.nih.gov/books/NBK532298
Khaitan PG, Famiglietti A, Watson TJ. The etiology, diagnosis, and management of esophageal perforation. J Gastrointest Surg. 2022;26(12):2606-15. doi:10.1007/s11605-022-05454-2
Knipe H, Kumar K, Ashraf, et al. Esophageal perforation. Radiopedia.org. December 2, 2013. radiopaedia.org/articles/oesophageal-perforation?lang=us
Kooji CD, Boptsi E, Weusten BLAM, de Vries DR, Ruurda JP, van Hillegersberg R. Treatment of Boerhaave syndrome: Experience from a tertiary center. Surg Endosc. 2025;39(4):2228-38. doi:10.1007/s00464-025-11540-8
Raymond DP. Esophageal perforation. UpToDate. February 9, 2026. uptodate.com/contents/esophageal-perforation
Shahriarirad R, Karoobi M, Shekouhi R, et al. Esophageal perforation, etiology, outcome, and the role of surgical management—An 18-year experience of surgical cases in a referral center. BMC Surg. 2023;23(1):177. doi:10.1186/s12893-023-02080-w
Sherrin S, Kochhar JK, Mustafa W, Batham K. Management of Boerhaave’s syndrome in the intensive care unit. Int J Crit Illn Inj
Key words: Mackler’s Triad, Boerhaave syndrome, chest pain, subcutaneous emphysema
