Spotting Boerhaave Syndrome in the ED: Hamman’s Crunch Time

-Case-

A 54-year-old man presents to the ED with sudden, severe chest pain that began shortly after an episode of forceful vomiting. He’s diaphoretic, tachycardic, and complains of neck discomfort and shortness of breath. He says the pain radiates to his back and worsens with swallowing. On exam, you note subtle crepitus in his neck and chest wall.

-Evaluation-

Boerhaave syndrome is a spontaneous esophageal rupture typically caused by a sudden increase in intraesophageal pressure, most commonly from forceful vomiting. It is a true full-thickness perforation and a surgical emergency with high mortality if missed.

  • Classic Presentation:
    • Sudden, severe chest pain after vomiting (“vomiting then pain”)
    • Pain may radiate to the back, neck, or abdomen
    • Dyspnea, dysphagia, or odynophagia
    • Subcutaneous emphysema or mediastinal crepitus (Hamman’s crunch)
  • Risk Factors:
    • Heavy alcohol use (binge drinking)
    • Bulimia or disordered eating
    • Iatrogenic (endoscopy, NG tube placement)

Diagnosis:

  • CXR may show pneumomediastinum, pleural effusion (usually left-sided), or subcutaneous emphysema
  • CT Chest with IV and oral contrast is the best initial imaging to evaluate for perforation
  • Water-soluble contrast esophagram (Gastrografin) can localize the leak

-Management in the ED-

  1. NPO: to prevent further contamination
  2. Broad-spectrum IV antibiotics: cover gram-negatives and anaerobes (e.g., piperacillin-tazobactam or cefepime + metronidazole)
  3. IV fluids and supportive care
  4. Surgical consultation ASAP
    • Definitive management often involves operative repair
    • In select contained cases, endoscopic stenting or conservative management may be considered

-Fast Facts-

  • Vomiting then sudden chest pain = Boerhaave until proven otherwise
  • Hamman’s crunch = mediastinal air movement; highly suggestive of perforation
  • Early antibiotics + surgical consult are critical to reduce mortality!
  • Mortality rises significantly with delayed diagnosis (>24 hours)

Boerhaave syndrome is rare, deadly, and frequently misdiagnosed. Sudden chest pain after vomiting and the presence of subcutaneous crepitus should immediately raise red flags. Early imaging, prompt antibiotics, and surgical intervention are your best shot at saving the patient. In the ED, when chest pain follows vomiting, think beyond the heart – think esophagus!

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

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Tamir Zitelny, MD

-References-

  1. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004;77(4):1475-1483. doi:10.1016/j.athoracsur.2003.08.037
  2. Kaman L, Iqbal J, Kundil B, Kochhar R. Management of esophageal perforation in adults. Gastroenterol Res Pract. 2010;2010:1-9. doi:10.1155/2010/845956
  3. Søreide JA, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011;19:66. doi:10.1186/1757-7241-19-66
  4. 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. Dig Surg. 2009;26(1):1-6. doi:10.1159/000193763
  5. Gupta NM, Kaman L. Personal management of 57 consecutive patients with esophageal perforation. Am J Surg. 2004;187(1):58-63. doi:10.1016/j.amjsurg.2002.12.020
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