A 50 year old man presented to his local emergency department complaining of central chest pain and breathlessness that had begun after an episode of vomiting. Physical examination revealed diminished breath sounds at the left lung base and a temperature of 38°C. An erect chest radiograph showed a small, left sided pleural effusion. An initial diagnosis of pneumonia was made, and the patient was started on intravenous antibiotics. The next morning he had deteriorated, and a repeat chest radiograph showed an increase in the pleural effusion and pneumomediastinum. Computed tomography with oral and intravenous contrast revealed contrast in the left pleural cavity, suggesting a diagnosis of oesophageal rupture. The patient was stabilised and subsequently underwent thoracotomy and wash-out, placement of an oesophageal stent, and insertion of a feeding jejunostomy. Spontaneous rupture of the oesophagus (Boerhaave’s syndrome) is a complete disruption of the oesophageal wall in the absence of pre-existing pathology and occurs with a sudden rise in intraoesophageal pressure, typically during vomiting. The left posterolateral lower oesophagus is most often affected, about 2-3 cm from the gastro-oesophageal junction. #### How common is spontaneous oesophageal rupture?