Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery.

[citation needed] In most cases of Boerhaave syndrome, the tear occurs at the left postero-lateral aspect of the distal esophagus and extends for several centimeters.

[5] The classic history of esophageal rupture is one of severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain.

[8] Pain can occasionally radiate to the left shoulder, causing physicians to confuse an esophageal perforation with a myocardial infarction.

[citation needed] 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.

With cervical esophageal perforations, plain films of the neck show air in the soft tissues of the prevertebral space.

[citation needed] Patients may also have a pleural effusion high in amylase (from saliva), low pH, and may contain particles of food.

[citation needed] Common misdiagnoses include myocardial infarction, pancreatitis, lung abscess, pericarditis, and spontaneous pneumothorax.

If esophageal perforation is suspected, even in the absence of physical findings, chest xray, water soluble contrast radiographic studies of the esophagus and a CT scan should be promptly obtained.