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This is a chest x-ray PA view showing a strip of air in the mediastinum (A) with evidence of subcutaneous emphysema on the anterior abdominal wall (B) and in the neck (C). These findings are typical of perforation of oesophagus.

The common causes are:

• Iatrogenic - (endoscopy induced).
• Foreign body ingestion.
• Spontaneous perforation - Boerhaave's syndrome.
  
• External trauma (penetrating and gun-shot injuries of chest).
  
• Corrosive ingestion.

Boerhaave's syndrome: Described by Hermann Boerhaave in 1724, this condition occurs with repeated vomiting after over-eating usually in an inebriated person. This causes spasm of the crico-pharyngeal sphincter when the rest of the oesophagus contracts leading to increased intra-oesophageal pressure causing perforation of the lower 1/3 on the left side.

This condition occurs in a middle-aged man who over-indulges in eating under the influence of alcohol and starts to vomit continuously. The manifestation consists of sudden onset of severe epigastric pain radiating to the left side of the chest and shoulder. This is followed by dyspnoea and shock. On examination the patient is in shock with tachycardia, cold/clammy skin, sweating, weak thready pulse and hypotension. There is surgical emphysema in the neck and chest wall extending into the anterior abdominal wall. There is tachypnoea, dullness and diminished air entry over the base of the left lung. There is guarding and tenderness in the upper abdomen. In patients who present late there are features of frank septicaemic shock.

The aim of management is to resuscitate the patient, to confirm the diagnosis and to institute definitive treatment. Adequate volume replacement with colloids and crystalloids through a wide bore cannula is carried out and a central line is inserted once the blood pressure is restored. Analgesia is achieved by Morphine or Pethidine, oxygen inhalation is given and second generation Cephalosporins with Metronidazole started. The diagnosis is confirmed by gastrograffin swallow. After confirming the diagnosis the definite treatment is carried out according to the time of presentation.

Early perforation: (< 24 hours old)

In these cases the chest is opened and mediastinum is thoroughly washed. The perforation is closed in two layers after debriding the edges. The tear in the mucosa is longer than the tear in the muscle. The repaired area is reinforced with pleural or diaphragmatic flap and the chest is drained. The operation is completed by doing a gastrostomy to prevent gastro-oesophageal reflux and a feeding jejunostomy.

Late presentation

The pleural cavity is drained and the patient is managed conservatively with antibiotics, IV fluids and nil by mouth. If there is gross mediastinal contamination with septic shock the chest is opened and lavage done to the mediastinum, but no attempt is made to close the perforation. The oesophageal perforation is covered with pleural or diaphragmatic flap and sutured to the healthy oesophageal wall. A proximal diversion cervical oesophagostomy is done and a distal feeding jejunostomy is performed. The chest is drained.

The prognosis of delayed presentation is poor.