Boerhaave syndrome (oesophageal rupture): a rare emergency after severe vomiting

The oesophagus is the tube that carries food from the throat to the stomach. Boerhaave syndrome is a type of oesophageal rupture in which the whole thickness of its wall tears, usually because pressure inside the oesophagus rises suddenly and sharply. Cleveland Clinic explains that at the same time the muscle at the top of the oesophagus does not relax as it should.

It is rare, and the UK health information that exists is mostly written for doctors. No dedicated NHS patient page was found when this guide was prepared, and the main UK reference that mentions it, a Patient.info article for clinicians on Mallory-Weiss syndrome, lists Boerhaave syndrome as an important condition to think of when someone has retching and vomiting blood. This guide therefore also uses two US patient information sources, Cleveland Clinic and MedlinePlus, and says so where it matters.

MedlinePlus puts Boerhaave syndrome in the wider group of oesophageal perforation, a hole in the oesophagus. It notes that the most common cause of a perforation overall is injury during a medical procedure, though the use of flexible instruments has made that uncommon, and lists violent vomiting (Boerhaave syndrome) among other causes such as tumours, reflux with ulceration, swallowed foreign objects or caustic chemicals and chest trauma.

Cleveland Clinic says symptoms usually begin quickly after vomiting or retching, and that the most common one is severe chest pain, although symptoms can vary depending on where the tear is. Some people have three classic features known as Mackler's triad, but most do not have all three, which makes the diagnosis harder.

• Severe chest pain, which may spread to the upper belly, neck, back or shoulder.

• Pain when swallowing, or trouble swallowing.

• Shortness of breath or fast breathing.

• Fever and sweating.

• A crackling sensation under the skin of the neck or chest, caused by trapped air (subcutaneous emphysema).

• Vomiting, which is part of the triad together with chest pain and air under the skin.

The NHS chest pain page says to call 999 if you get sudden pain or discomfort in the chest that does not go away, pain that spreads to the arm, neck, jaw, stomach or back, or chest pain with sweating, sickness, light-headedness or shortness of breath, because you could be having a heart attack and need immediate treatment in hospital. Those instructions apply equally here, as the two emergencies can look alike.

Cleveland Clinic advises seeking emergency care right away for severe chest pain after vomiting, especially with trouble breathing, severe belly pain, neck swelling, a crackling feeling under the skin or fever, and not waiting to see if symptoms improve. In the UK the equivalent is 999 or A&E. The NHS says not to drive yourself to A&E.

The NHS page on vomiting blood says to call 999 or go to A&E if you are vomiting blood and feel generally unwell, confused, faint or dizzy, have rapid or shallow breathing, cold clammy pale skin, tummy pain or black poo. It lists damage to the food pipe from being sick or coughing a lot among the causes of vomiting blood.

Forceful vomiting and repeated retching are the most common causes, according to Cleveland Clinic. Less often the tear follows heavy lifting, severe straining, childbirth, seizures or a hard blow to the chest.

It says you are more likely to have it if you drink large amounts of alcohol, binge eat, have bulimia, or have conditions affecting the oesophagus such as eosinophilic oesophagitis, a narrowing, or acid reflux with oesophageal ulcers, but that most people who develop Boerhaave syndrome have an otherwise healthy oesophagus. Anyone can be affected.

Cleveland Clinic says a doctor will ask about the symptoms, examine you and order imaging, usually starting with a CT scan of the chest, which can show air, fluid or other signs that the oesophagus has torn. If more information is needed, a barium swallow (oesophagram) may be done, in which you swallow a special liquid while X-rays are taken, and leakage outside the oesophagus confirms the tear. Blood tests and a chest X-ray are used to look for infection or other complications.

MedlinePlus lists the signs doctors look for as fast breathing, fever, low blood pressure, rapid heart rate, and air bubbles under the skin if the perforation is in the upper part of the oesophagus, and says chest X-rays, X-rays after drinking a harmless dye and CT scans can pinpoint the location and look for an abscess.

Cleveland Clinic says Boerhaave syndrome requires immediate treatment in hospital. This may include intravenous fluids, intravenous antibiotics, medicine to reduce stomach acid, and nutrition through a feeding tube or drip if needed. Many people need surgery or an upper endoscopy to close the tear. If the tear is small with little leakage, surgical repair may not be needed, but the care team monitors closely. If fluid or infection collects around the lungs it may need to be drained.

MedlinePlus says surgery depends on the location and size of the perforation and, if needed, is best done within 24 hours, and that a stent may be placed in the oesophagus if only a small amount of fluid has leaked, which may avoid surgery. Surgery is often needed for perforations in the middle or lower oesophagus, and may involve a simple repair or, depending on the extent of the problem, removing the oesophagus.

Cleveland Clinic says recovery depends on how large the tear is, how quickly treatment begins and whether complications develop. Many people stay in hospital for several weeks and may need a feeding tube while the oesophagus heals, and the team checks that the tear has healed before normal eating restarts. Full recovery may take weeks to months, with follow-up visits and imaging.

MedlinePlus says the condition can progress to shock or even death if untreated, that most people survive when surgery is done within 24 hours, and that survival falls the longer treatment is delayed. Possible complications include permanent narrowing or stricture of the oesophagus, abscesses and infection in and around the lungs. These sources do not give reliable UK survival figures, and your hospital team can explain what applies to you.

Both can follow vomiting or retching. Cleveland Clinic explains that a Mallory-Weiss tear is a tear in the inner lining of the oesophagus that causes bleeding without a full-thickness tear, so you may vomit blood, whereas Boerhaave syndrome is a tear through the entire wall that lets contents leak into the chest. The Patient.info clinical article notes that Mallory-Weiss syndrome is usually diagnosed by endoscopy and that Boerhaave syndrome belongs in the differential diagnosis when there is retching and sudden bleeding.

Boerhaave syndrome is managed through emergency departments, then specialist surgical teams in hospital, which is the same route on the NHS or in a private hospital with an emergency unit. Because the first hours matter, the practical advice is to go to the nearest A&E by ambulance, tell staff that the pain began after vomiting, and let them decide on the imaging.