Episode four closes the chapter with two emergencies that run on the same cue-plus-threshold-plus-intervention shape, where the threshold is a mechanism in disguise. For esophageal perforation the clock starts when the wall tears, and the twenty-four hour window separates clean primary closure from sealed stent and drainage because the mediastinal tissue planes change from friend to enemy. For acute colonic pseudo-obstruction the clock starts when the colon stops moving, and a four-step algorithm anchored by a cecal-diameter threshold and a neostigmine-with-cardiac-monitoring decision moves the patient from the conservative bundle to pharmacology to decompression to surgery. Laplace's law explains why the cecum fails first and the neostigmine contraindication list explains why every dose comes with atropine at the bedside. Topics covered Causes of esophageal perforation and Boerhaave The Mackler triad and recognition stem Perforation site and left-sided effusion Water-soluble contrast imaging and antibiotics The twenty-four hour repair-versus-stent window Ogilvie syndrome and autonomic imbalance Ruling out mechanical obstruction Neostigmine and cardiac monitoring Colonoscopic decompression and surgery Key decisions Image suspected esophageal perforation with CT chest and oral water-soluble contrast looking for pneumomediastinum, avoiding barium initially because barium granulomatous mediastinitis is a feared complication, since a normal chest radiograph does not exclude the diagnosis. Cover both mediastinal compartments with piperacillin-tazobactam or a meropenem-based regimen plus antifungal coverage in severe disease, and place nasogastric decompression under fluoroscopic guidance to avoid the leak. Repair Boerhaave and large iatrogenic perforations primarily within twenty-four hours while tissue planes hold, shift beyond twenty-four hours to covered self-expanding metal stents with drainage, and clip small iatrogenic perforations caught at the index endoscopy. Rule out mechanical obstruction and volvulus first in suspected Ogilvie syndrome with CT showing a dilated colon without a transition point, because a mechanical cause will not respond to neostigmine and may perforate during conservative management. Manage the first forty-eight to seventy-two hours conservatively with decompression, electrolyte correction, and stopping opioids and anticholinergics, then escalate at cecal diameter over twelve centimeters, persistent distension, or impending perforation because Laplace's law makes the cecum fail first. Give neostigmine two milligrams intravenously over three to five minutes with mandatory cardiac monitoring and atropine at the bedside, honor the contraindication list, and move to colonoscopic decompression then surgery when it fails or is contraindicated. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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