A rare but important cause of chest pain

An 83-year-old Caucasian man presented to our institution with a 16-hour history of eight episodes of vomiting which was later associated with frank haematemesis and severe epigastric/chest pain. There was no past history of note and he denied consumption of non-steroidal anti-inflammatory medications or alcohol. On clinical examination he was haemodynamically stable and there was no stigmata of surgical emphysema. Digital rectal examination did not show any evidence of melaena or haematochezia. Routine haematological, biochemical and inflammatory markers were normal. An erect chest radiograph was normal. He underwent an oesophago-gastroduodenoscopy (OGD) within 24 h of admission, which revealed a 7.5 cm tear within the midoesophagus, 27 cm ab oral, with views into the mediastinum (see Figure 1a). A diagnosis of Boerhaave’s syndrome was made. An urgent computed tomography (CT) scan revealed free mediastinal air, in keeping with a full thickness tear of the oesophagus, (see Figure 1 b). A covered metal oesophageal stent was inserted (Boston Scientific, Hemel Hempstead, UK), with a surgical feeding jejunostomy sited the following day and broad-spectrum intravenous antibiotics instituted. A water-soluble contrast study one month postadmission showed no leakage, (see Figure 2) and he was discharged five weeks after admission. The oesophageal stent was removed six weeks after presentation.