Boerhaave's syndrome is spontaneous esophageal rupture resulting from a sudden increase in internal esophageal pressure. The mortality rate is very high and increases when treatments are delayed. However, this disease is not only very rare with atypical clinical manifestations, but also not sensitive enough to be detected by the early chest X-ray, so misdiagnosis or delay diagnosis are quite common. We reported a 85-year-old male who felt chest pain, abdominal pain and dyspnea just after having a big meal. When he visited emergency department 5 hours later, the chest X-ray revealed mild infiltration in left lower lobe. However, there was a significant change in the second chest X-ray 11 hours after onset. Computed tomography of chest revealed significant air bubbles in the mediastinum with fluid accumulation at the surrounding region of the esophagus. The following operation confirmed the diagnosis ultimately. We suggests that patients with unexplained and unimproved chest pain should be followed closely with repeated physical examinations and a series of chest X-rays.
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