A middle-aged man presented to the emergency department with upper abdominal pain after having a heavy meal. On clinical examination, upper abdominal tenderness was noted. On chest radiography widening of the mediastinum with pneumomediastinum was seen. What is the probable diagnosis?

Explanation

## Correct Answer: A. Spontaneous perforation of esophagus Spontaneous perforation of the esophagus (Boerhaave syndrome) is the classic diagnosis when a patient presents with upper abdominal pain following a heavy meal, combined with **mediastinal widening and pneumomediastinum** on chest radiography. The discriminating feature here is the **pneumomediastinum**—air tracking into the mediastinal space—which occurs when the esophageal wall ruptures, allowing intraluminal air and gastric contents to escape into the mediastinum and pleural spaces. Boerhaave syndrome typically follows forceful vomiting or retching after a large meal, causing a sudden rise in intraesophageal pressure that exceeds the esophageal wall's tensile strength. The classic triad includes severe chest/upper abdominal pain, subcutaneous emphysema, and pneumomediastinum. Unlike Mallory-Weiss tears (which cause hematemesis but not perforation), Boerhaave is a full-thickness rupture. The condition is a surgical emergency requiring immediate esophageal repair, as mortality exceeds 40% if diagnosis is delayed beyond 24 hours. In the Indian context, this diagnosis is often missed initially because patients present with nonspecific upper abdominal pain mimicking acute gastroenteritis or peptic ulcer disease, but the radiological finding of pneumomediastinum is pathognomonic and mandates urgent surgical intervention. ## Why the other options are wrong **B. Rupture of emphysematous bulla of lung** — While a ruptured emphysematous bulla can cause pneumomediastinum and pneumothorax, it typically presents with acute dyspnea and chest pain rather than upper abdominal pain after a heavy meal. The clinical context of post-prandial pain and forceful vomiting is absent. Additionally, bullae rupture is more common in young patients with COPD, not middle-aged men presenting acutely after eating. The absence of respiratory distress makes this less likely. **C. Foreign body in esophagus** — Foreign body impaction can cause esophageal obstruction and pain, but it does **not** typically cause pneumomediastinum unless perforation has already occurred. The presence of pneumomediastinum on imaging indicates a breach in the esophageal wall, not merely obstruction. Foreign bodies usually present with dysphagia or drooling, and the acute presentation with mediastinal widening points to perforation rather than simple impaction. **D. Perforation of peptic ulcer** — Peptic ulcer perforation does cause acute upper abdominal pain and can lead to pneumoperitoneum (free air under the diaphragm), but **not pneumomediastinum**. The key discriminating finding here is pneumomediastinum with mediastinal widening, which is characteristic of esophageal rupture, not gastric or duodenal perforation. Peptic ulcer perforation presents with board-like rigidity and free air in the peritoneal cavity, not the mediastinum. ## High-Yield Facts - **Boerhaave syndrome** = spontaneous full-thickness esophageal rupture, typically after forceful vomiting; mortality >40% if delayed >24 hours. - **Pneumomediastinum** on chest X-ray is the pathognomonic radiological sign of esophageal perforation; mediastinal widening indicates mediastinitis. - **Classic triad**: severe chest/upper abdominal pain, subcutaneous emphysema, and pneumomediastinum following forceful retching or heavy meal. - **Mallory-Weiss tear** (partial thickness) causes hematemesis but NOT perforation; Boerhaave is full-thickness with air leak into mediastinum. - **Surgical emergency**: requires immediate esophageal repair (primary closure or esophagectomy depending on timing and contamination); conservative management has >90% mortality. ## Mnemonics **BOERHAAVE = Post-Prandial Perforation** **B**oerhaave = **B**urst esophagus after **B**ig meal; **O**pen (full-thickness rupture); **E**mergency surgery needed; **R**etching/vomiting trigger; **H**eavy meal precedes; **A**ir in mediastinum (pneumomediastinum); **A**cute pain; **V**ery high mortality if delayed; **E**sophageal repair urgent. **Pneumomediastinum = Esophageal Perforation** When you see **pneumomediastinum** on CXR in a patient with acute upper abdominal pain post-meal → think **Boerhaave** first. Mediastinal widening + air = esophageal breach, not gastric or lung pathology. ## NBE Trap NBE pairs pneumomediastinum with lung pathology (emphysematous bulla rupture) to distract from the clinical context of post-prandial pain and forceful vomiting, which is pathognomonic for esophageal rupture. The trap is focusing on the radiological finding alone without integrating the clinical history. ## Clinical Pearl In Indian emergency departments, Boerhaave syndrome is frequently misdiagnosed as acute gastroenteritis or peptic ulcer perforation because patients present with nonspecific upper abdominal pain. The key is to always obtain a chest X-ray in acute upper abdominal pain—if pneumomediastinum is present, surgical consultation is mandatory within hours, not days, to prevent mediastinitis and sepsis. _Reference: Bailey & Love Ch. 27 (Esophagus); Sabiston Textbook of Surgery Ch. 39_