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In spontaneous perforation of the thoracic esophagus, or Boerhaave's syndrome, a sudden, dramatic increase in intraluminal esophageal pressure causes a full-thickness perforation of normal underlying esophageal tissue with ensuing mediastinitis, sepsis, and shock. Most cases result from violent retching or vomiting after an alcoholic binge. The perforations usually occur as 1- to 4-cm vertically oriented linear tears on the left posterolateral wall of the distal esophagus just above the gastroesophageal junction.

The classic triad of vomiting, lower thoracic chest pain, and subcutaneous emphysema is virtually pathognomonic of Boerhaave's syndrome. Unfortunately, spontaneous esophageal perforations are rarely diagnosed within 24 hours of their occurrence. Unlike cervical esophageal perforations, which can often be treated conservatively, thoracic esophageal perforations generally require immediate thoracotomy with surgical closure of the tear and mediastinal drainage to prevent the development of mediastinitis, sepsis, and death. The overall mortality for all patients with thoracic esophageal perforations is about 25%.

About 90% of patients with thoracic esophageal perforations have abnormal chest radiographs with mediastinal widening, pneumomediastinum, pleural effusion, and/or hydropneumothorax. Most patients with distal perforations have left-sided pleural effusions.

The presence and location of a thoracic esophageal perforation can be confirmed by the use of water-soluble contrast material. Because most thoracic esophageal perforations occur near the gastroesophageal junction, contrast is usually seen extravasating from the left lateral aspect of the distal esophagus into the adjacent mediastinum, as in this patient (Film .2).