Background <p>Boerhaave syndrome is a life-threatening condition caused by a spontaneous full-thickness rupture of the esophagus, typically following forceful vomiting. Esophageal variceal rupture is another potentially fatal condition commonly observed in patients with liver cirrhosis. These two conditions are usually reported independently, and their coexistence is extremely rare. Managing this combination is particularly challenging because of the need for both infection control and hemostasis in the presence of portal hypertension.</p> Case presentation <p>We report the case of a 51-year-old man with liver cirrhosis (Child–Pugh Grade B) and a history of endoscopic variceal ligation, who presented with hematemesis followed by vomiting. He had not consumed any alcohol at that time and exhibited no signs of melena. Computed tomography revealed mediastinal emphysema, right-sided hemopneumothorax, and esophageal perforation. Endoscopy confirmed a lower esophageal tear with active variceal bleeding. Emergency surgery was performed via a right thoracotomy. A 35-mm longitudinal tear in the lower esophagus was identified and sutured; however, owing to tissue fragility and signs of infection, a T-tube was placed at the perforation site. The patient had an uneventful postoperative course, resumed oral intake on postoperative day 17, and was discharged without any complications on day 46.</p> Conclusions <p>This was a rare case of Boerhaave syndrome complicated by ruptured esophageal varices. Surgical management with T-tube drainage was effective in controlling both infection and bleeding. Patients with esophageal varices may be at an increased risk of esophageal rupture, especially following vomiting. Awareness of this association is essential for timely diagnosis and management.</p>