Boerhaave Syndrome

Document Type : Review Article


1 Gastroenterologist, Department of Internal Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

2 General Practitioner, Mashhad University of Medical Sciences, Mashhad, Iran


Boerhaave syndrome (BS) is a spontaneous esophageal perforation and is a life-threating but uncommon disorder. This syndrome involves a transmural perforation and typically occurs after forceful emesis. The prognosis is dependent on rapid diagnosis and correct management. The classic presentation of BS consists of vomiting, subcutaneous emphysema, and lower thoracic pain. However, significant symptoms and signs rarely occur, about one-third of all patients are clinically atypical. Thus, BS should be suspected in patients presenting any sudden thoracoabdominal pain with a history of emesis. The chest radiograph is the most helpful diagnostic aid, in addition to CT scans for further evaluations.When the clinical condition allows for a less invasive approach, non-operative treatment should be considered, with or without the use of an endoscopic stent or placement of internal or external drains. The best prognosis of Boerhaave's syndrome is associated with early diagnosis and surgical care within 12 hours of perforation.


1.             Curci JJ, Horman MJ. Boerhaave's syndrome: The importance of early diagnosis and treatment. Annals of surgery. 1976;183(4):401-8.
2.             Walker WS, Cameron EW, Walbaum PR. Diagnosis and management of spontaneous transmural rupture of the oesophagus (Boerhaave's syndrome). The British journal of surgery. 1985;72(3):204-7.
3. Abbott, 0. A. et al.: Atraumatic so-called "spontaneous" rupture of the esophagus, J. Thorac. Cardiovasc. Surg., 59:67, 1970.
4.             Teh E, Edwards J, Duffy J, Beggs D. Boerhaave's syndrome: a review of management and outcome. Interactive cardiovascular and thoracic surgery. 2007;6(5):640-3.
5.             Khan AZ, Strauss D, Mason RC. Boerhaave's syndrome: diagnosis and surgical management. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2007;5(1):39-44.
6.             Soreide JA, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scandinavian journal of trauma, resuscitation and emergency medicine. 2011;19:66.
7.Spapen J, De Regt J, Nieboer K, Verfaillie G, Honoré PM, Spapen H. Boerhaave's Syndrome: Still a Diagnostic and Therapeutic Challenge in the 21st Century. Case Rep Crit Care. 2013;2013:161286.
8.Wolfson D, Barkin JS. Treatment of Boerhaave's Syndrome. Curr Treat Options Gastroenterol. 2007 Feb;10(1):71-7.
9.             Whyte RI. Boerhaave's syndrome. The New England journal of medicine. 2001;344(2):139.
10.          Turut H, Gulhan E, Adams PY, Cetin G. Successful conservative management of Boerhaave's syndrome with late presentation. Journal of the National Medical Association. 2006;98(11):1857-9.
11.Witz M, Jedeikin R, Zager M, Shpitz B, Elyashiv A, Dinbar A. Spontaneous rupture of the distal oesophagus (Boerhaave's syndrome) with unusual clinical presentation of pneumoperitoneum. Post-grad Med J. 1984;60(699):60–61.
12. Kollmar O, Lindemann W, Richter S, Steffen I, Pistorius G, Schilling MK. Boerhaave's syndrome: primary repair vs. esophageal resection—case reports and meta-analysis of the literature. J Gastrointest Surg. 2003;7(6):726–34.
13. Salo JA, Isolauri JO, Heikkilä LJ, Markkula HT, Heikkinen LO, Kivilaakso EO, Mattila SP. Management of delayed esophageal perforation with mediastinal sepsis. Esophagectomy or primary repair? J Thorac Cardiovasc Surg. 1993;106(6):1088–1091.
14.          Ryom P, Ravn JB, Penninga L, Schmidt S, Iversen MG, Skov-Olsen P, et al. Aetiology, treatment and mortality after oesophageal perforation in Denmark. Danish medical bulletin. 2011;58(5):A4267.
15.          Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience. The Annals of thoracic surgery. 2011;92(1):209-15.
16.          Vidarsdottir H, Blondal S, Alfredsson H, Geirsson A, Gudbjartsson T. Oesophageal perforations in Iceland: a whole population study on incidence, aetiology and surgical outcome. The Thoracic and cardiovascular surgeon. 2010;58(8):476-80.
17.          Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. The Annals of thoracic surgery. 2004;77(4):1475-83.
18.Kish GF, Katske FA. A case of recurrent Boerhaave's syndrome. W V Med J. 1980 Feb. 76(2):27-30. 
19.Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg. 1986 Sep. 42(3):235-9. 20.Restrepo CS, Lemos DF, Ocazionez D, Moncada R, Gimenez CR. Intramural hematoma of the esophagus: a pictorial essay. Emergency radiology. 2008;15(1):13-22.
21. Ghanem N, Altehoefer C, Springer O, Furtwängler A, Kotter E, Schäfer O, et al. Radiological findings in Boerhaave's syndrome. Emerg Radiol. 2003;10:8–13.
22. Shaker H, Elsayed H, Whittle I, Hussein S, Shackcloth M. The influence of the ‘golden 24-h rule’ on the prognosis of oesophageal perforation in the modern era. Eur J Cardiothorac Surg. 2010;38:216–22.
23. Derbes VJ, Mitchell RE., Jr Hermann Boerhaave's Atrocis, nec descripti prius, morbi historia, the first translation of the classic case report of rupture of the esophagus, with annotations. Bull Med Libr Assoc. 1955;43:217–40.
24. Buecker A, Wein BB, Neuerburg JM, Guenther RW. Esophageal perforation: Comparison of use of aqueous and barium-containing contrast media. Radiology. 1997;202:683–6.
25.  Rochford M, Kiernan TJ. "Images in emergency medicine, Boerhaave's syndrome (spontaneous esophageal rupture).". Ann Emerg Med. 2007;49(6):746–77. doi: 10.1016/j.annemergmed.2006.10.011.
26.  Griffin SM, Lamb PJ. "Spontaneous rupture of the oesophagus.". Br J Surg. 2008;95(9):1115–20. doi: 10.1002/bjs.6294.
27.  Mackler SA. Spontaneous rupture of the esophagus; an experimental and clinical study. Surg Gynecol Obstet. 1952;95:345–356.
28.          Gimenez A, Franquet T, Erasmus JJ, Martinez S, Estrada P. Thoracic complications of esophageal disorders. Radiographics : a review publication of the Radiological Society of North America, Inc. 2002;22 Spec No:S247-58.
29.  Naclerio's V Sign1: Signs in Imaging, Sinha R Radiology. 2007. pp. 296–297
30.  Onyeka WO, Booth SJ. Boerhaave's syndrome presenting as tension pneumothorax. Journal of Accident & Emergency Medicine. 1999;16:235–236.
31.  Sajith A, O'Donohue B, Roth RM, Khan RA. CT scan findings in oesophagogastric perforation after out of hospital cardiopulmonary resuscitation. Emerg Med J. 2008;25:115–116. doi: 10.1136/emj.2006.044008.
32.  Exarhos DN, Malagari K, Tsatalou EG, Benakis SV, Peppas C, Kotanidou A, Chondros D, Roussos C. Acute mediastinitis: spectrum of computed tomography findings. Eur Radiol. 2005;15:1569–1574. doi: 10.1007/s00330-004-2538-3.
33.  Huber-Lang M, Henne-Bruns D, Schmitz B, Wuerl P. Esophageal perforation: principles of diagnosis and surgical management. Surg Today. 2006;36:332–340. doi: 10.1007/s00595-005-3158-5.
34.  Young CA, Menias CO, Bhalla S, Prasad SR. CT features of esophageal emergencies. Radiographics. 2008;28:1541–1553. doi: 10.1148/rg.286085520.
35. Arantes V, Campolina C, Valerio SH, de Sa RN, Toledo C, Ferrari TA, Coelho LG. Flexible esophagoscopy as a diagnostic tool for traumatic esophageal injuries. J Trauma. 2009;66:1677–1682. doi: 10.1097/TA.0b013e31818c1564.
36.  Bresadola V, Terrosu G, Favero A, Cattin F, Cherchi V, Adani GL, Marcellino MG, Bresadola F, De Anna D. Treatment of perforation in the healthy esophagus: analysis of 12 cases. Langenbecks Arch Surg. 2008;393:135–140. doi: 10.1007/s00423-007-0234-x.
37.  Neel D, Davis EG, Farmer R, Richardson JD. Aggressive operative treatment for emetogenic rupture yields superior results. Am Surg. 2010;76:865–868.
38.          de Schipper JP, Pull ter Gunne AF, Oostvogel HJ, van Laarhoven CJ. Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm. Digestive surgery. 2009;26(1):1-6.
39.          Vial CM, Whyte RI. Boerhaave's syndrome: diagnosis and treatment. The Surgical clinics of North America. 2005;85(3):515-24, ix.
40.          Ghanem N, Altehoefer C, Springer O, Furtwangler A, Kotter E, Schafer O, et al. Radiological findings in Boerhaave's syndrome. Emergency radiology. 2003;10(1):8-13.
41.          Abbas G, Schuchert MJ, Pettiford BL, Pennathur A, Landreneau J, Landreneau J, et al. Contemporaneous management of esophageal perforation. Surgery. 2009;146(4):749-55; discussion 55-6.
42.          Kiernan PD, Rhee J, Collazo L, Hetrick V, Vaughan B, Graling P. Complete esophageal diversion: a simplified, easily reversible technique. Journal of the American College of Surgeons. 2005;200(5):812; author reply -3.