Boerhaave syndrome with mediastinal, axillary, neck and epidural free gas

Case contributed by Vikas Shah
Diagnosis almost certain


Young male presents with chest pain following a bout of vomiting.

Patient Data

Age: 20 years
Gender: Male

Streaky linear lucency is seen surrounding the cardiac outline and adjacent to the great vessels in the superior mediastinum. Similar streaky lucency is also seen within the soft tissues of the neck and the right axilla. There is no pneumothorax or pleural effusion.

The CT, acquired after the chest xray, confirms a pneumomediastinum, and free gas in the following locations:

  • soft tissue spaces of the neck
  • around the great vessels
  • chest wall
  • epidural space of the spinal canal


Case Discussion

The chest xray and CT show the classic features of Boerhaave syndrome. The mechanism is a focal linear full thickness tear of the esophageal wall following severe vomiting or retching, leading to gas dissecting through the mediastinum. The gas can then escape into other soft tissue spaces. Gas can also dissect into the peritoneal and retroperitoneal spaces.

A CT with oral contrast can be acquired to attempt to identify the site of the leak but often it will have sealed immediately, and to look for mediastinal or pleural collections. Focal esophageal thickening or an intramural hematoma may also be seen.

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