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From the question on page 644
Food debris was drained out from the chest tube 36 h after admission. Distal oesophageal rupture was confirmed by an oesophagogram (fig 11),), which showed a massive leakage (arrow) of barium to the mediastinum and left pleural space (arrowheads). The patient was diagnosed with Boerhaave's syndrome complicated with secondary pleural effusion.
Boerhaave's syndrome is an uncommon clinical entity, which is defined as spontaneous oesophageal rupture excluding perforations resulting from iatrogenic instrumentation or foreign bodies. Classic presentation of Mackler's triads, vomiting, chest pain and subcutaneous emphysema are not common. Atypical presentations include asymptomatic pleural effusion, dyspnoea secondary to pneumothorax or hydrothorax, or haematemesis. The presence of pneumomediastinum or pneumothorax offers important clues for diagnosis, and should be carefully looked for on the chest radiograph. The most typical chest x ray finding is left‐sided hydropneumothorax, which is secondary to left posterolateral oesophageal rupture due to inherited anatomical weakness. Primary surgical repair of the perforation is the definite treatment. The best results are achieved when operative repair is within 12 h of rupture. Rising mortality can be expected if surgery is delayed owing to increasing frequency of complications.