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Esophageal rupture
Medical expert of the article
Last reviewed: 12.07.2025
Esophageal rupture may be iatrogenic during endoscopic procedures or other manipulations or spontaneous (Boerhaave syndrome). The patients' condition is severe, with signs of mediastinitis. The diagnosis is established by esophagography with a water-soluble contrast agent. Emergency suturing of the esophagus and drainage are necessary.
[ What causes an esophageal rupture?
Endoscopic procedures are the leading cause of esophageal rupture, but spontaneous rupture is usually associated with vomiting, retching, or ingestion of a large piece of food. The most common rupture is distal to the left side. Acid and stomach contents cause fulminant mediastinitis and shock. Pneumomediastinum is common.
Symptoms of Esophageal Rupture
Symptoms of esophageal rupture include chest pain, abdominal pain, vomiting, hematemesis, and shock. Subcutaneous emphysema is found in approximately 30% of patients. Mediastinal crepitations (Hamman's sign) and crepitating sounds synchronous with heart contractions may be detected.
Diagnosis of esophageal rupture
Mediastinal air, pleural fluid, and mediastinal widening seen on chest and abdominal X-rays suggest the diagnosis. The diagnosis is confirmed by esophagography with a water-soluble contrast agent, which does not cause significant mediastinal irritation, unlike barium. Chest CT shows mediastinal air and fluid but does not localize the perforation well. Endoscopy may miss a small perforation.
Treatment of esophageal rupture
In the preoperative period, patients should be given broad-spectrum antibiotics (eg, gentamicin and metronidazole or piperacillin/tazobactam) and given fluid resuscitation as for shock. Even if the esophageal rupture is treated, mortality is high.