Esophageal Perforation With Right-Sided Hemothorax in a Patient With Suspected Variceal Bleeding: A Diagnostic Challenge

Esophageal perforation (Boerhaave syndrome) is a rare but life-threatening condition that may mimic other causes of upper gastrointestinal bleeding, making early diagnosis challenging. We report a 76-year-old woman with disseminated breast cancer who presented with massive hematemesis and profound hemodynamic instability, initially suspected to represent variceal bleeding. Emergency endoscopy achieved hemostasis at the gastroesophageal junction but did not identify a perforation. During anesthesia, point-of-care ultrasound revealed a large right-sided pleural effusion, prompting CT imaging. CT demonstrated a massive right-sided hydropneumothorax, complete lung collapse, and mediastinal air consistent with esophageal perforation. Despite stabilization and broad-spectrum antibiotics, the patient developed sepsis. Given her advanced malignancy, frailty, and poor prognosis, invasive interventions were withheld and care was transitioned to a palliative approach. This case highlights the diagnostic difficulty of distinguishing Boerhaave syndrome from other causes of massive hematemesis and underscores the value of CT imaging when endoscopy is inconclusive.