Perforation allows gastric contents and bacteria to leak into mediastinum; this is rare but often deadly if not surgically repaired within 24 hours.
Patients experience severe chest, neck, and shoulder pain with dysphagia and potentially shock. Notice that the pain pattern resembles that of myocardial infarction.
We also look for Hamman's sign, which is a crunching or rasping sound caused by the heart beating in a pneumomediastinum (aka, mediastinal emphysema - air in the mediastinum).
Perforation is usually iatrogenic (often from endoscopy) but can also be caused by the ingestion of foreign bodies, or by trauma.
Boerhaave syndrome is perforation due to violent vomiting.
Recall that Mallory-Weiss tears are tears in the distal esophagus and are often due to vomiting.
