Spontaneous oesophageal rupture, also known as Boerhaave syndrome (BS), is a life-threatening benign disease of the gastrointestinal tract  that typically results from a sudden increase in intraoesophageal pressure such as forceful retching or severe vomiting  and most frequently occurs in the left wall of the lower third of the oesophagus, a site that is anatomically vulnerable . BS, to our knowledge, has been demonstrated in various patients, including those with gastrointestinal stenosis, Barrett's oesophagus, ileus, and frequent vomiting during continued chemotherapy or gastroscopy and after general anaesthesia . However, in our case, the patient's esophageal wall tear was unusually secondary to oral magnesium sulfate administration, and second, most unique to our case, his rupture was located in the right wall of the distal oesophagus, which was in disagreement with the most frequent site of perforation reported . To our knowledge, this is the first published case worldwide demonstrating esophageal rupture located in the right wall after taking magnesium sulfate. A study revealed that the incidence of spontaneous oesophageal perforation was 3.1/1,000,000 per year, which is an extremely rare entity , and the common presentations of BS, including chest or epigastric pain, vomiting, dyspnea and shock, are vulnerable to misdiagnosis as other entities, such as entities cardiogenic in origin, gastrointestinal perforation, acute pancreatitis and abdominal aortic aneurysms . Due to the low incidence rate and high misdiagnosis rate of BS, the diagnosis and therapy of BS are often delayed, resulting in a high mortality and significant complication rate. Hence, prompt diagnosis and immediate therapeutic interventions are extremely necessary.
Studies have found that early manifestations in most cases of BS commonly include sudden upper abdominal pain or chest pain after severe vomiting, which then rapidly radiates to the substernal area, shoulders or back, accompanied by dyspnea, chest tightness, fever or other symptoms. This characteristic history is of great significance for the diagnosis of BS . In addition, images including plain chest roentgenograms, oesophagograms, and CT scans also contribute to diagnosing BS . Previous studies have shown that the oesophagogram is a feasible and effective examination for diagnosing oesophageal perforation ; however, due to the high false-negative rate of the oesophagogram (15-25%) and tenuous nature of oesophageal rupture, chest CT is considered a more appropriate modality [5, 7]. The typical findings of chest radiography and CT are subcutaneous emphysema, pneumomediastinum, pleural effusion, pneumothorax, and so on . Recent studies have revealed that gastroscopy can help definitively confirm the diagnosis and offer timely interventional treatment . For this patient, his characteristic history, physical examination and findings from imaging were sufficiently consistent with BS, which vastly raised our suspicion of BS, and gastroscopy eventually confirmed this diagnosis. Since the establishment of our hospital, this is the first patient with oesophageal rupture after administration of OSS, even worldwide.
Data from the literature indicate that the golden period for primary repair is the first 24 hours of the event for oesophageal perforation when it can be associated with a 90% success rate . The principles of treatment include removing the source of pollution, closing the breach, restoring the integrity of the oesophagus, full drainage, controlling the infection, strengthening nutritional support, improving the body and promoting wound healing [3, 8]. The traditional management of BS has been prompt surgery . Recently, new primary repair methods with interventional endoscopy have been performed widely. One of these is the endoscopic clip device. Endoscopic repair with clips has evolved as an effective, easy, cheap and minimally invasive alternative to primary surgery . In our case, we used endoscopic clips to close the oesophageal defect. The procedure was smooth, he recovered well after the operation and was discharged successfully.