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.

● 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.