BACKGROUND: Spontaneous esophageal rupture is a life-threatening emergency caused by a rapid increase in intraesophageal pressure. Timely diagnosis and surgical intervention are crucial for survival. Typical cases involve vomiting-related rupture of the left distal esophagus with left pleural effusion. However, atypical presentations, including right-sided rupture, have been reported and can contribute to delayed diagnosis. Cases occurring in association with acute irreducible inguinal hernia are extremely rare; their clinical significance and optimal management remain unclear. Such atypical presentations may hinder accurate diagnosis.

CASE REPORT: A 70-year-old Japanese woman presented with acute-onset epigastric pain after experiencing nausea and retching without vomiting. Imaging revealed pneumomediastinum, right pleural effusion, right pneumothorax, and a right inguinal hernia containing small bowel. Based on the clinical presentation and imaging findings, spontaneous esophageal rupture associated with retching in the context of an acute irreducible inguinal hernia was diagnosed. Given the atypical right-sided presentation and absence of definitive bowel obstruction, careful diagnostic evaluation was required to avoid misdiagnosis. Thoracoscopic primary repair and chest drainage were performed approximately 3 hours after symptom onset. The hernia was manually reduced and subsequently managed with elective laparoscopic repair. The postoperative course was uneventful, without major complications or recurrence.

CONCLUSIONS: This case suggests an association between acute irreducible inguinal hernia and spontaneous esophageal rupture through retching-related increases in intraesophageal pressure, although a direct causal relationship cannot be definitively established. Prompt imaging, timely thoracoscopic repair, and staged management of coexisting abdominal pathology may contribute to favorable outcomes, even in cases of atypical right-sided perforation.

Keywords: Esophageal Perforation, Hernia, Inguinal, Pneumothorax, Thoracic Surgery