A 49-year-old man presents to the emergency department with severe chest pain that began immediately after multiple episodes of forceful vomiting following an evening of heavy alcohol consumption. He reports painful swallowing and shortness of breath. Past medical history is significant for hypertension which is treated with losartan. Temperature is 38.1°C (100.6°F), blood pressure is 102/64 mm Hg, pulse is 116/min, and respiratory rate is 24/min. Physical examination reveals subcutaneous crepitus over the neck and upper chest. Chest radiography demonstrates mediastinal air.
Which of the following is the most likely diagnosis?
The correct answer is:
A) Boerhaave syndrome
This patient has classic findings of Boerhaave syndrome, a full-thickness esophageal rupture that occurs after forceful vomiting. Severe chest pain, subcutaneous emphysema, and pneumomediastinum are hallmark findings. The condition is a medical emergency because leakage of esophageal contents into the mediastinum can rapidly lead to mediastinitis and sepsis.
Answer choice B: Gastroesophageal reflux disease, is incorrect.
GERD can cause substernal discomfort and chest pain. However, it does not cause sudden severe symptoms following vomiting or produce subcutaneous emphysema and mediastinal air.
Answer choice C: Mallory-Weiss tear, is incorrect.
Both Boerhaave syndrome and Mallory-Weiss tear can follow forceful vomiting, making this the most attractive distractor. However, Mallory-Weiss tears are mucosal lacerations that typically present with hematemesis rather than pneumomediastinum. This answer would be correct in a patient with upper gastrointestinal bleeding after retching.
Answer choice D: Myocardial infarction, is incorrect.
Acute chest pain should always raise concern for myocardial infarction. However, the temporal relationship to vomiting and the presence of subcutaneous emphysema strongly support esophageal rupture.
Answer choice E: Peptic ulcer disease, is incorrect.
Peptic ulcer disease usually presents with epigastric pain and may cause bleeding or perforation. It does not explain mediastinal air after forceful emesis.
Key Learning Point
Boerhaave syndrome is a full-thickness esophageal rupture characterized by severe chest pain, subcutaneous emphysema, and pneumomediastinum following forceful vomiting.
