Although barium is superior in demonstrating small perforations, the spillage of barium sulfate into the mediastinal and pleural cavities can cause an inflammatory response and subsequent fibrosis and is therefore not used as the primary diagnostic study. If, however, the water-soluble study is negative, a barium study should be performed for better definition.Endoscopy has no role in the diagnosis of spontaneous esophageal perforation. Both the endoscope and insufflation of air can extend the perforation and introduce air into the mediastinum.Patients may also have a pleural effusion high in amylase (from saliva), low pH, and may contain particles of food. Differential diagnosis
Common misdiagnoses include myocardial infarction, pancreatitis, lung abscess, pericarditis, and spontaneous pneumothorax. If esophageal perforation is suspected, even in the absence of physical findings, chest xray, water soluble contrast radiographic studies of the esophagus and a CT scan should be promptly obtained. In most cases, non-operative management is administered based on radiological evidence contained in mediastinal collection. Treatment
With the exception of a few case reports describing survival without surgery, the mortality of untreated Boerhaave syndrome is  100%. Its treatment includes immediate antibiotic therapy to prevent mediastinitis and sepsis, surgical repair of the perforation, and if there is significant fluid loss it should be replaced with IV fluid therapy since oral rehydration is not possible. Even with early surgical intervention (within 24 hours) the risk of death is 25%. References
Further reading
Radiology  Esophageal rupture
Arens, Ann; Ben-Youssef, Leila; Hayashi, Sandra; Smollin, Craig (2016). "Esophageal Rupture After Ghost Pepper Ingestion". The Journal of Emergency Medicine. 51 (6): e141–e143.
doi:10.1016/j.jemermed.2016.05.061. PMID 27693067. Henderson, John A.M.; Péloquin, AndréJ.M. (1989). "Boerhaave revisited: Spontaneous esophageal perforation as a diagnostic masquerader". The American Journal of Medicine. 86 (5): 559–67. doi:10.1016/0002-9343(89)90385-9. PMID 2653030. Larrieu, AJ; Kieffer, R (1975). "Boerhaave syndrome: report of a case treated non-operatively". Annals of Surgery. 181 (4): 452–4. doi:10.1097/00000658-197504000-00015. PMC 1343787. PMID 1130863. Patton, Anthony S.; Lawson, Dexter W.; Shannon, James M.; Risley, Thomas S.; Bixby, Frank E. (1979). "Reevaluation of the Boerhaave syndrome". The American Journal of Surgery. 137 (4): 560–5. doi:10.1016/0002-9610(79)90131-4. PMID 426207. Ivey, Tom D.; Simonowitz, David A.; Dillard, David H.; Miller, Donald W. (1981). "Boerhaave syndrome". The American Journal of Surgery. 141 (5): 531–3. doi:10.1016/0002-9610(81)90040-4. PMID 6784584. == External links ==