Spontaneous Esophageal Rupture (Boerhaave) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Hemodynamically stable?
   Chest pain after forceful vomiting — is the patient hemodynamically stable? (Transmural esophageal perforation after forceful vomiting (usually distal left posterolateral); delay causes mediastinitis/sepsis (24–48 h, high mortality). The Mackler triad (vomiting + chest pain + subcutaneous emphysema) is complete in only a minority, ~1/3 atypical → often misdiagnosed as MI/PE/aortic dissection/pneumothorax/perforated ulcer; severe lower chest/upper abdominal pain after vomiting radiating to the back/left shoulder, worse on swallowing, usually no hematemesis, often a left pleural effusion. Diagnosis: CXR (pneumomediastinum/left effusion/subcutaneous air), CT (first-line, extraluminal air/contrast leak), water-soluble contrast esophagram to localize in stable patients.)
   • Unstable / large leak / septic → Unstable/large leak → emergency surgery
   • Stable / contained localized leak → Stable/contained leak · conservative + drainage
2. [End] Stable/contained leak · conservative + drainage
   Stable, contained localized leak: nil by mouth, IV fluids, broad-spectrum antibiotics (± antifungals) + PPI, drain collections (chest tube); endoscopic options (stent/clip) may be considered; monitor closely, convert to surgery if worsening. Urgent thoracic surgery co-management.
3. [End] Unstable/large leak → emergency surgery
   Hemodynamically unstable / large leak / early (<24 h) / septic: emergency surgery (primary repair + drainage, diversion if needed); concurrently nil by mouth, aggressive fluid resuscitation, broad-spectrum antibiotics + PPI, drain the pleura/mediastinum; ICU. Delay causes mediastinitis → septic shock with poor prognosis — act fast.

Source guidelines & references

• Spontaneous esophageal rupture, Boerhaave (StatPearls; Medscape)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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