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Esophageal Rupture

by Michael C. DiMarino, MD

Esophageal rupture may be iatrogenic during endoscopic procedures or other instrumentation or may be spontaneous (Boerhaave syndrome). Patients are seriously ill, with symptoms of mediastinitis. Diagnosis is by esophagography with a water-soluble contrast agent. Immediate surgical repair and drainage are required.

Endoscopic procedures are the primary cause of esophageal rupture, but spontaneous rupture may occur, typically related to vomiting, retching, or swallowing a large food bolus. The most common site of rupture is the distal esophagus on the left side. Acid and other stomach contents cause a fulminant mediastinitis and shock. Pneumomediastinum is common.

Symptoms and Signs

Symptoms include chest and abdominal pain, vomiting, hematemesis, and shock. Subcutaneous emphysema is palpable in about 30% of patients. Mediastinal crunch (Hamman sign), a crackling sound synchronous with the heartbeat, may be present.


  • Chest and abdominal x-rays

  • Esophagography

Chest and abdominal x‑rays showing mediastinal air, pleural effusion, or mediastinal widening suggest the diagnosis. Diagnosis is confirmed by esophagography with a water-soluble contrast agent, which avoids potential mediastinal irritation from barium. CT of the thorax detects mediastinal air and fluid but does not localize the perforation well. Endoscopy may miss a small perforation.


  • Surgical repair

Pending surgical repair, patients should receive broad-spectrum antibiotics (eg, gentamicin plus metronidazole or piperacillin/tazobactam) and fluid resuscitation as needed for shock. Even with treatment, mortality is high.

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