spontaneous esophageal perforation , or boerhaave s syndrome , is a life - threatening condition that usually requires early diagnosis and surgical treatment . it is a form of transmural esophageal rupture caused by a rapid rise in intraluminal pressure   and most often occurs in the distal posterolateral aspect of the esophagus . the upside down stomach is defined as a gastric volvulus in a huge supradiaphragmatic sac   and is the rarest type of hiatal hernia . this condition can result in acute gastric outlet obstruction as well as ischemia and perforation of the stomach . we report a patient with an esophageal perforation in the presence of an upside down stomach . this is the first report of a patient with boerhaave s syndrome and an upside down stomach . a 79-year - old woman with a previous medical history of cerebral infarction and hypertension developed sudden - onset epigastric pain radiating to the back following hematemesis and presented to the emergency department her peripheral blood pressure was 119/71  mmhg , pulse 110/min , and percutaneous oxygen saturation 93% on room air . her temperature was 38.0  c and the serum c - reactive protein was elevated ( 4.27  mg / dl ) although the white blood cell count was normal . initially , we suspected a diagnosis of peptic ulcer with hematemesis , and upper gastrointestinal endoscopy was performed . this revealed a deep ulcerated lesion on the left side of the distal esophagus and the endoscope could not pass through to the distal stomach because the stomach was twisted toward the proximal portion ( fig . a computed tomography ( ct ) scan showed frank pneumomediastinum and a left pleural effusion , suggesting boerhaave s syndrome . in addition , coronal views on the ct scan revealed an upside down appearance of the stomach with a mesentero - axial volvulus ( fig . 2 ) . a gastrografin swallow showed extravasation of contrast in the left chest , confirming the diagnosis of boerhaave s syndrome ( fig . a left thoracotomy was performed with drainage and irrigation of the mediastinum and pleural space . a 2  cm diameter perforation was found just above the cardia on the left side of the esophagus . the site of perforation had normal appearing edges , and primary repair was performed with a two - layer closure of the mucosa and muscularis . since there was an upside down stomach , a gastrostomy was placed to fix and decompress the stomach . in addition , the lower mediastinal space was covered with an omental patch to maintain the correct orientation of the stomach . a postoperative gastrografin swallow showed normal passage of contrast without leakage and normal position of the stomach . the pathophysiology of boerhaave s syndrome involves a sudden elevation in intraluminal esophageal pressure , with transmural perforation . repeated bouts of vomiting often precede the perforation , commonly occurring after ingestion of alcohol . many patients with boerhaave s syndrome present with vague symptoms , and diagnostic delays are common . the most common misdiagnosis is perforated ulcer , followed by myocardial infarction , pulmonary embolism , dissecting aneurysm and pancreatitis , . earlier evaluation of the chest x - ray may have suggested alternative diagnoses since over 90% of patients with boerhaave s syndrome have abnormalities on chest x - ray . previous reports describe that the perforation is located most often ( 80% ) on the left side of the lower third of the thoracic esophagus measuring 36  cm on average . another report described that the presence of a pre - existing stricture or large perforation ( > 5  cm ) is associated with the need for urgent esophagectomy . the present patient also had a gastric volvulus , referred to as an upside down stomach , and we suggest that this was the cause of the esophageal perforation . gastric volvulus is classified into three types according to the axis of rotation , including organo - axial ( rotation around the long axis connecting the cardia and the pylorus ) , mesenterico - axial ( rotation around the short axis connecting the lesser and greater curvatures ) and combined ( rotation around both the short and long axes ) , . in general , an upside down stomach can result in acute gastric outlet obstruction as well as ischemia and perforation of the stomach . this is the first report of a patient with boerhaave s syndrome resulting from an upside down stomach . we performed not only primary closure of the esophageal perforation but also fixation of the stomach by placing a gastrostomy tube to prevent recurrence of the volvulus . fixation of the stomach by a placement of a percutaneous endoscopic gastrostomy has been described in a patient with gastric volvulus in poor condition . postoperative gastrografin swallow showed passage of contrast though the stomach , maintained in its normal location . perforation of the esophagus as well as perforation of the stomach must be considered in patients with an upside down stomach . this study was supported in part by the ministry of education , culture , sports , science and technology of japan . this paper is not research study , so i assume we do not need the ethical approval . all authors in this manuscript contributed to the interpretation of data , and drafting and writing of this manuscript . ss , yh , kk , sm , tu , hh and rk were engaged in patient s care in her hospital coarse including surgery under the supervision of al , jk and ns . all authors have read and approved this manuscript for publication . dr . sata , who is the president of jichi medical university hospital , is the guarantor .
highlightsupside down stomach and boerhaave s syndrome are rare clinical entities.gastric volvulus with a large supradiaphragmatic sac is referred to as an upside down stomach , and can result in esophageal as well as gastric perforations.this is the first report of a patient with boerhaaves s syndrome resulting from an upside down stomach .