Boerhaave’s Syndrome

Boerhaave’s syndrome (or Boerhaave syndrome) is a rare, serious tear through the entire wall of your esophagus. This is the tube that carries food to your stomach. The tear happens after sudden, severe pressure builds up in your esophagus. It most often occurs after intense vomiting. Boerhaave (pronounced "boor-hah-vuh”) syndrome is a type of esophageal rupture.

A torn esophagus is a medical emergency. Food, liquid and bacteria can leak into your chest through the tear. This can lead to a serious infection called sepsis. Without urgent treatment, Boerhaave’s syndrome can be life-threatening. The sooner treatment begins, the better the chance of recovery.

Boerhaave’s syndrome symptoms

Symptoms of Boerhaave’s syndrome usually begin quickly after vomiting or retching. The most common symptom is severe chest pain, but symptoms can vary depending on where the tear is.

Other symptoms may include:

• Pain in your upper belly, neck, back or shoulder
• Trouble swallowing or pain when swallowing
• Shortness of breath
• Fast breathing
• Fever
• Sweating
• A crackling sensation when you touch your neck or chest, due to air trapped under your skin (subcutaneous emphysema)

Some people have three classic symptoms, called Mackler’s triad:

• Vomiting
• Chest pain
• Air trapped under your skin

But most people don’t have all three symptoms. This can make Boerhaave’s syndrome harder to diagnose.

Boerhaave’s syndrome causes

Boerhaave’s syndrome happens when pressure inside your esophagus suddenly becomes too high. At the same time, the muscle at the top of your esophagus doesn’t relax the way it should. The pressure can become strong enough to tear the wall of your esophagus.

Forceful vomiting and repeated retching are the most common causes. Less often, the tear can happen after:

• Heavy lifting
• Severe straining
• Childbirth
• Seizures
• A hard blow to your chest

Risk factors

Anyone can develop Boerhaave’s syndrome. But you’re more likely to have it if you:

• Drink large amounts of alcohol
• Binge eat
• Have bulimia
• Have certain conditions that affect your esophagus, like eosinophilic esophagitis, narrowing in your esophagus or acid reflux with esophageal ulcers

Most people who develop Boerhaave’s syndrome have a typical, healthy esophagus.

Complications of this condition

Without treatment, Boerhaave’s syndrome can cause serious complications. This is because food, stomach fluids and bacteria leak outside your esophagus.

Complications may include:

• Infection in your chest
• Pus around your lungs
• Fluid around your lungs
• Collapsed lung
• Sepsis
• Septic shock
• Organ failure

Getting treatment as soon as possible lowers your risk of these complications.

How doctors diagnose this condition

Boerhaave’s syndrome can be hard to diagnose because its symptoms are similar to those of other emergencies, including a heart attack. Your healthcare provider will ask about your symptoms and do a physical exam.

They’ll also order imaging tests. A CT scan of your chest is usually the first one. It can show air, fluid or other signs that your esophagus has torn.

If your provider needs more information, you may have a barium swallow (esophagram). During this test, you’ll swallow a special liquid while X-rays are taken. If the liquid leaks outside your esophagus, it confirms the tear.

You may also need blood tests or a chest X-ray to look for infections or other complications.

Treatment for Boerhaave’s syndrome

Boerhaave’s syndrome requires immediate treatment in the hospital. Your treatment may include:

• IV fluids
• IV antibiotics
• Medicine to reduce stomach acid
• Nutrition through a feeding tube or IV, if needed

Many people need surgery or an upper endoscopy to close the tear. If you have a small tear and little leakage, you may not need surgical repair. But your care team will closely monitor you in the hospital. If fluid or an infection builds up around your lungs, your provider may need to drain it.

Recovery time

Recovery is different for everyone. It depends on how large the tear is, how quickly treatment begins and whether complications develop. Many people stay in the hospital for several weeks.

While your esophagus heals, you may need a feeding tube. Before you start eating normally again, your provider will make sure the tear has healed.

Full recovery may take weeks to months.

When should I see my healthcare provider?

Boerhaave’s syndrome is a medical emergency. Call 911 or go to the nearest emergency department right away if you have severe chest pain after vomiting, especially if you also have:

• Trouble breathing
• Severe belly pain
• Neck swelling
• A crackling feeling under your skin
• Fever

Don’t wait to see if your symptoms get better. Early treatment can save your life.

What can I expect if I have this condition?

Your outlook depends mostly on how quickly you get treatment. If your provider finds and treats Boerhaave’s syndrome early, you may recover well.

You’ll likely need follow-up visits and imaging tests to make sure your esophagus heals fully. If your provider thinks another condition may have caused the tear, you may need more testing after you recover.

Boerhaave’s syndrome can be life-threatening if you don’t get treatment right away. Delays in diagnosis and treatment increase the risk of serious infection and death. Getting emergency care as soon as symptoms begin gives you the best chance of recovery.

What’s the difference between Boerhaave’s syndrome and Mallory-Weiss syndrome?

Both Boerhaave’s syndrome and Mallory-Weiss syndrome can happen after vomiting or retching. But they’re different types of injuries.

A Mallory-Weiss tear is a tear in the inner lining of your esophagus. It causes bleeding without a full thickness tear, so you may vomit blood.

Boerhaave’s syndrome is more serious. It’s a tear through the entire wall of your esophagus. This lets food, liquid and bacteria leak into your chest. It’s a medical emergency that needs immediate treatment.