A66-year-old man presented with a 2-day history of worsening upper abdominal pain, vomiting and constipation. He appeared in severe discomfort and was retching profusely. His symptoms had become worse over the past 48 hours, and in this time he had not been able to open his bowels. He had mild learning difficulties since childhood and had previously been diagnosed with an epigastric hernia, which had been asymptomatic. On examination he was obese, dehydrated and tachycardic, but had oxygen saturations of over 95% and was not tachypnoeic. He had a palpable irreducible epigastric mass, which was very tender to touch, and bowel sounds were noted to be increased. Digital rectal examination was unremarkable as was the remainder of his physical examination. An initial diagnosis of obstructed epigastric hernia was made, and the patient was resuscitated with intravenous fluid and oxygen. Erect chest and abdominal X-rays were performed to exclude a perforated viscus and to confirm the level of obstruction. The abdominal X-ray was unremarkable, but the chest X-ray (Figure 1) revealed an abnormally wide mediastinum containing air. There was, however, no evidence of a pneumothorax and, when the patient was re-examined, he had no surgical emphysema. An urgent computerized tomography (CT) scan of the chest and abdomen was organized but, while being scanned, the patient's condition suddenly deteriorated. He became visibly distressed and short of breath and, as a result, the scan was rapidly completed and the patient sat up and administered oxygen. Review of the thoracic CT scan revealed a right-sided haemopneumothorax, pneumomediastinum, and a left-sided pleural effusion (Figure 2). The abdominal CT (Figure 3) demonstrated his epigastric hernia containing a grossly distended stomach and several dilated loops of small bowel. A diagnosis of oesophageal rupture secondary to severe emesis (Boerhaave's syndrome) owing to irreducible epigastric hernia was made, and a right thoracic drain inserted. This immediately drained 2 litres of blood-stained fluid, which was litmus tested, indicating acid content. Following further resuscitation, the patient was taken to theatre for a laparotomy and right-sided thoracotomy. At operation the epigastric hernia sac was found to contain much of the greater curve of the stomach. The neck of the sac was subsequently widened and contents returned to the abdominal cavity. Formal laparotomy was otherwise unremarkable, and right-sided thoracotomy performed. This revealed a collapsed right lung with gastric contents in the pleural and mediastinal spaces, and a complete tear at the distal oesophagus (approximately 30 cm). Owing to the friability of the oesophageal tissue surrounding the perforation, primary repair was not attempted and a ‘T-tube’ was inserted into the perforation with the defect repaired over this, in order to produce a controlled fistula. A feeding jejunostomy and drainage enterogastrostomy tube were also inserted. Finally, the epigastric hernia defect was repaired and the abdomen was closed. Postoperatively, the patient spent 5 days in the intensive care unit and was then transferred to the ward where he received 6 weeks of intravenous antibiotics. A soluble contrast swallow performed on the 52nd postoperative day revealed that the oesophageal perforation had sealed and the patient was discharged from hospital shortly after.
