Question

A patient presents with epigastric pain after a heavy meal. On examination there is tenderness and rigidity in the upper abdomen, and the chest X-ray shows pneumomediastinum. The most likely cause is:

• A. Spontaneous oesophageal rupture (Boerhaave syndrome)
• B. Penetrating foreign body injury to the oesophagus
• C. Perforated peptic ulcer
• D. Rupture of an emphysematous bulla

Hint:

Vomiting then chest pain then air in the mediastinum points to which named syndrome?

Answer 1

The Correct Option is A

Correct option: Spontaneous oesophageal rupture (Boerhaave syndrome).
Step 1: The history of severe chest or upper-abdominal pain after a large meal or bout of vomiting, with pneumomediastinum on imaging, is classic for Boerhaave syndrome (a full-thickness barotrauma rupture, usually of the lower-left oesophagus).
Step 2: Mackler triad confirms the diagnosis: vomiting, then chest pain, then subcutaneous emphysema. Air tracks into the mediastinum, giving the pneumomediastinum and the V sign of Naclerio on chest X-ray.
Why the others are wrong: There is no history of a swallowed foreign body. A perforated peptic ulcer gives free gas under the diaphragm (pneumoperitoneum), not pneumomediastinum. A ruptured emphysematous bulla causes a pneumothorax in a patient with chronic lung disease, not this post-meal picture.
Ref: Bailey and Love, Short Practice of Surgery, 27th edition, 2018; SRB's Manual of Surgery, 4th edition.