A 27-Year-Old Man With Hyperemesis and Hematemesis

Gerard J. Fitzmaurice, BSc, MBBCh BAO; Robin Brown, MD, FRCS; Mark E. O'Donnell, DSEM, MFSEM, MRCS; Fionnuala Mone, MBBCh BAO; Angela McGreevy, MBBCh BAO


June 27, 2017


This 27-year-old man presented in an acutely deteriorating state and was quickly diagnosed with multiorgan failure caused by underlying sepsis. The erect chest radiograph was a key diagnostic tool in this case, because it demonstrated air along the left heart border and the aortic knob, representing pneumomediastinum and/or pneumopericardiac air (Figure 1). This finding led to urgent CT of the chest and abdomen, which found free air within the mediastinum and the pericardial sac (Figure 2).

Figure 1.

Figure 2.

The patient then underwent a contrast-enhanced swallow study (not available), which failed to demonstrate a patent esophageal leak, thus indicating that the rupture had probably occurred earlier.

Boerhaave syndrome, or spontaneous esophageal rupture, is a rare but serious condition with a mortality rate ranging from 25% to 89%. If treatment is instituted within 24 hours of the appearance of symptoms, the mortality rate is 25%; however, mortality rates rise to greater than 65% after 24 hours without treatment and 75%-89% after 48 hours without treatment.[1]

The syndrome is characterized by a complete transmural rupture of the esophagus resulting from barogenic trauma (ie, forceful vomiting).[2] A sudden rise in intraluminal pressure caused by uncoordinated vomiting with pyloric closure and diaphragmatic contraction against a contracted cricopharyngeal muscle is theorized to be the underlying cause of Boerhaave syndrome.[3] Perforation usually occurs at the weakest point of the esophagus; therefore, the most common site of rupture is the left posterolateral wall of the lower third of the esophagus. This is seen in 90% of patients.[4]

Although Boerhaave syndrome is relatively rare (accounting for only 16% of all traumatic ruptures of the esophagus), it has been associated with a heterogeneous population, affecting all races worldwide.[2,3] An association has been noted between overindulgence in alcohol and food, as is expected from a condition that is associated with vomiting.[3] Boerhaave syndrome has a significantly increased incidence in men compared with women, with a ratio of approximately 2:1.[3] It is also more common in middle-aged individuals; 80% of patients are middle-aged men.[3] Despite this, studies consistently report that Boerhaave syndrome affects all age groups, from neonates to those aged 90 years.[2,3]


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