Oesophageal perforation/rupture

Classically described following a forceful vomiting (Boerhaave syndrome).
Commoner causes include – iatrogenic trauma, blunt/penetrating trauma, chemical injury, foreign body perforation, spontaneous rupture and postoperative breakdown.
The oesophagus has no serosal covering and hence perforation allows direct access to the mediastinum.
Perforation of the upper/cervical oesophagus allows access to the retropharygeal space.
Perforation of the lower/mid-oesophagus tends to directly enter the mediastinum. Inflammatory reaction causes contamination of the pleural space.This is facilitated by negative pleural pressure.

Oesophageal rupture. Air is seen outlining the right side of the mediastinum

CXR: Classic signs are subcutaneous emphysema, pneumomediastinum, left sided pleural effusion, hydropneumothorax and mediastinal widening.
Cervical spine: Lateral views may reveal retropharyngeal air.
Pleural effusions, pulmonary infiltrates and a true mediastinal air–fluid level are not typically seen with a spontaneous pneumomediastinum.
Water soluble contrast studies are of benefit to demonstrate perforations. If no perforation is seen a barium swallow will show better mucosal detail.These studies can be repeated over time.

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