Answer for BIR CoW 14 Dec 2025
BOERHAAVE SYNDROME
Findings
Evidence of peripherally enhancing hypodense collection with internal air pockets noted in the supradiaphragmatic region along the left postero-medial mediastinum. Multiple airpockets noted in superior and left posteromedial mediastinum – Pneumomediastinum Left mild pleural effusion with subsegmental collapse of left basal segments of lower lobe. On oral dynamic contrast administration, there is no active contrast extravasation into the collection. IMPRESSION: Contained Esophageal perforation – Boerhaave syndrome and pneumomediastinum.
FOLLOWUP: Patient was taken up for surgery – Loop Cervical esophagostomy with total esophageal exclusion and feeding jejunostomy
Discussion
Boerhaave syndrome typically occurs after forceful emesis and retching. Boerhaave syndrome is a transmural perforation of the esophagus and should be distinguished from Mallory-Weiss syndrome, a nontransmural esophageal tear also associated with vomiting. Since the perforation occurs with emesis, Boerhaave syndrome is usually not truly spontaneous, but this term helps distinguish it from iatrogenic perforation. Vomiting is the most common cause, but any activity that increases intraesophageal pressure can result in this syndrome. This condition can manifest in patients with a typically functioning esophagus, yet there is a subgroup where specific esophageal abnormalities or pathology are identified. Boerhaave syndrome accounts for 10% to 15% of all esophageal perforations. Boerhaave syndrome is classically associated with the Mackler triad of vomiting, chest pain, and subcutaneous emphysema. Most common risk factors include alcoholism and overindulgence in food. Other causes that raise pressure within the esophagus include weightlifting, defecation, epileptic seizures, abdominal trauma, compressed air injury, and childbirth. IMAGING: Chest radiograph findings: Non-specific, and the radiograph may be normal. The classic chest radiographic findings include pneumomediastinum, left pleural effusion and left pneumothorax. Gas may also be seen within the soft tissue spaces of the chest wall and the neck. In up to 20% of cases, the Nacleario V-sign may be seen as radiolucent streaks that dissect the retrocardiac fascia to form the letter V. This is a specific but insensitive radiographic sign of esophageal perforation. Contrast esophagogram: A water-soluble contrast agent such as Gastrografin should be used since extravasation of barium can lead to mediastinitis and subsequent fibrosis. The sensitivity of this study is dependent upon the size and location of the perforation and technique. False-negative results occur in 10% to 38% of cases. CT imaging: It provides more detail regarding the location of drainable collections and aids in localizing the rupture site. A contrast medium may further define the injury extent and assist in a timely diagnosis. CT findings may include periesophageal and mediastinal gas, mediastinal fluid collections, esophageal wall thickening, pleural effusion, pneumothorax, and hydrothorax. Differential diagnosis: 1. Esophageal perforation from iatrogenic injury 2. Mallory-weiss tear: partial thickness tear 3. Epiphrenic diverticulum: mimicking pneumomediastinum 4. Esophageal or pulmonary malignancy causing esophagopleural fistula The 3 common treatment modalities for Boerhaave syndrome include nonsurgical, endoscopic, and surgical (open vs minimally invasive). Mallory weiss tear vs Boerhaave syndrome: Location: Gastroesophageal junction (GEJ) - Left posterolateral distal esophagus (90%) CT Findings: Usually normal - Pneumomediastinum, periesophageal air, mediastinitis Chest X-ray: Normal - Mediastinal air, widened mediastinum, left pleural effusion Pleural Findings: None - Left-sided pleural effusion, hydropneumothorax Mediastinum: Normal - Air-fluid levels, soft tissue stranding, inflammation Associated Signs: None - Hamman’s sign, subcutaneous emphysema (seen on CT/X-ray)
REFERNCES: 1. Turner AR, Collier SA, Turner SD. Boerhaave Syndrome. [Updated 2023 Dec 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430808/ 2. Radswiki T, Kelly H, Weerakkody Y, et al. Boerhaave syndrome. Reference article, Radiopaedia.org (Accessed on 13 Nov 2025) https://doi.org/10.53347/rID-12730
Findings
Evidence of peripherally enhancing hypodense collection with internal air pockets noted in the supradiaphragmatic region along the left postero-medial mediastinum. Multiple airpockets noted in superior and left posteromedial mediastinum – Pneumomediastinum Left mild pleural effusion with subsegmental collapse of left basal segments of lower lobe. On oral dynamic contrast administration, there is no active contrast extravasation into the collection. IMPRESSION: Contained Esophageal perforation – Boerhaave syndrome and pneumomediastinum.
FOLLOWUP: Patient was taken up for surgery – Loop Cervical esophagostomy with total esophageal exclusion and feeding jejunostomy
Discussion
Boerhaave syndrome typically occurs after forceful emesis and retching. Boerhaave syndrome is a transmural perforation of the esophagus and should be distinguished from Mallory-Weiss syndrome, a nontransmural esophageal tear also associated with vomiting. Since the perforation occurs with emesis, Boerhaave syndrome is usually not truly spontaneous, but this term helps distinguish it from iatrogenic perforation. Vomiting is the most common cause, but any activity that increases intraesophageal pressure can result in this syndrome. This condition can manifest in patients with a typically functioning esophagus, yet there is a subgroup where specific esophageal abnormalities or pathology are identified. Boerhaave syndrome accounts for 10% to 15% of all esophageal perforations. Boerhaave syndrome is classically associated with the Mackler triad of vomiting, chest pain, and subcutaneous emphysema. Most common risk factors include alcoholism and overindulgence in food. Other causes that raise pressure within the esophagus include weightlifting, defecation, epileptic seizures, abdominal trauma, compressed air injury, and childbirth. IMAGING: Chest radiograph findings: Non-specific, and the radiograph may be normal. The classic chest radiographic findings include pneumomediastinum, left pleural effusion and left pneumothorax. Gas may also be seen within the soft tissue spaces of the chest wall and the neck. In up to 20% of cases, the Nacleario V-sign may be seen as radiolucent streaks that dissect the retrocardiac fascia to form the letter V. This is a specific but insensitive radiographic sign of esophageal perforation. Contrast esophagogram: A water-soluble contrast agent such as Gastrografin should be used since extravasation of barium can lead to mediastinitis and subsequent fibrosis. The sensitivity of this study is dependent upon the size and location of the perforation and technique. False-negative results occur in 10% to 38% of cases. CT imaging: It provides more detail regarding the location of drainable collections and aids in localizing the rupture site. A contrast medium may further define the injury extent and assist in a timely diagnosis. CT findings may include periesophageal and mediastinal gas, mediastinal fluid collections, esophageal wall thickening, pleural effusion, pneumothorax, and hydrothorax. Differential diagnosis: 1. Esophageal perforation from iatrogenic injury 2. Mallory-weiss tear: partial thickness tear 3. Epiphrenic diverticulum: mimicking pneumomediastinum 4. Esophageal or pulmonary malignancy causing esophagopleural fistula The 3 common treatment modalities for Boerhaave syndrome include nonsurgical, endoscopic, and surgical (open vs minimally invasive). Mallory weiss tear vs Boerhaave syndrome: Location: Gastroesophageal junction (GEJ) - Left posterolateral distal esophagus (90%) CT Findings: Usually normal - Pneumomediastinum, periesophageal air, mediastinitis Chest X-ray: Normal - Mediastinal air, widened mediastinum, left pleural effusion Pleural Findings: None - Left-sided pleural effusion, hydropneumothorax Mediastinum: Normal - Air-fluid levels, soft tissue stranding, inflammation Associated Signs: None - Hamman’s sign, subcutaneous emphysema (seen on CT/X-ray)
REFERNCES: 1. Turner AR, Collier SA, Turner SD. Boerhaave Syndrome. [Updated 2023 Dec 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430808/ 2. Radswiki T, Kelly H, Weerakkody Y, et al. Boerhaave syndrome. Reference article, Radiopaedia.org (Accessed on 13 Nov 2025) https://doi.org/10.53347/rID-12730
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!