Commonest cause of esophageal perforation: March 2007

Ans. D: Instrumentation Instrumentation is by far the most common cause of perforation Boerhaave syndrome/Esophageal perforation, is rupture of the esophageal wall caused by excessive vomiting in eating disorders such as bulimia although it may rarely occur in extremely forceful coughing or other situations, such as obstruction by food. It can cause pneumomediastinum and/or mediastinitis (air or inflammation of the mediastinum) and sepsis. Boerhaave syndrome is a transmural perforation of the esophagus, distinct from Mallory-Weiss syndrome, a nontransmural esophageal tear also associated with vomiting. The term is useful for distinguishing it from iatrogenic perforation, which accounts for 85-90% of cases of esophageal rupture, typically as a complication of an endoscopic procedure, feeding tube, or unrelated surgery. It is associated with "Mackler's triad" which consists of vomiting, lower thoracic pain and subcutaneous emphysema which the later can be heard as Haman's crunch on physical examination. The most common anatomical location of the tear in Boerhaave syndrome is at left posterolateral wall of the lower third of the esophagus, 2-3 cm before the stomach.