Circumferential intramural esophageal dissection successfully treated by endoscopic procedure and metal stent insertion

Chronic esophageal dissection: Delayed diagnosis in a 15-year-old male

Esophageal dissection is a rare condition, characterized by disruption of the submucosa from the muscular layer of the esophageal wall. It is commonly iatrogenic in etiology and patients typically present with acute onset dysphagia, odynophagia, and retrosternal pain. The condition can be diagnosed endoscopically; however, contrast swallow studies either with CT or fluoroscopy carry less risk and are the imaging investigations of choice for this condition. Patients are managed conservatively in the majority of cases. In this case report, we present a case of chronic esophageal dissection in a 15-year-old male who had undergone endoscopic removal of a foreign body from the esophagus several years prior. We discuss the clinical features, radiological diagnosis, and management of this condition.

Rare spontaneous extensive annular intramural esophageal dissection with endoscopic treatment: A case report

BACKGROUND

Intramural esophageal dissection (IED) is a rare disease that should be considered in patients with chest pain, dysphagia, and hematemesis. Although it occurs most frequently in older adult women with impaired coagulation or as a sequela of endoscopy, the incidence of spontaneous IED without an obvious causative agent has risen gradually.

CASE SUMMARY

This report describes a case of extensive annular IED in a 75-year-old male patient who presented with dysphagia for the past month. Esophageal barium meal radiography revealed slow passage of diluted iohexol through the esophagus after swallowing, prominent luminal dilation, obstruction of the lower segment with only a small amount of contrast medium entering the gastric cavity, and no obvious extravasation. Gastroscopy revealed smooth esophageal mucosa; several esophageal mucosal bridges and webbed mucosa were observed approximately 22 cm from the incisor. The mucosal surface was occasionally rough and uneven, and the length of the esophageal mucosal defect exceeded 10 cm. The anatomy was considered to be annular because the mucosal bridge connecting the proximal and distal tube was not attached to the surrounding myotubes. The final diagnosis was spontaneous extensive annular IED. We treated the patient successfully using endoscopic esophagotomy, which completely relieved the symptoms without complications.

CONCLUSION

Spontaneous annular IED can be treated successfully by endoscopic resection of the mucosal septum between the true and false lumen.

A case of submucosal abscess of the esophagus mimicking a mediastinal abscess

We report a case of a submucosal abscess of the esophagus that required differentiation from a mediastinal abscess. A 48-year-old man presented with a chief complaint of fever and sore throat. He did not remember swallowing a foreign body, and his oral cavity showed no signs of inflammation. Contrast-enhanced computed tomography showed a low density area with enhancement in the mediastinum, especially around the esophageal wall. We planned to perform surgical drainage with the intention of performing intraoperative endoscopy from the beginning. We performed surgical drainage through a left cervical oblique incision; however, there was no exudate obtained from the mediastinal space. Despite the reported absence of accidental ingestion of a foreign substance, intraoperative endoscopy was performed that revealed a laceration in the esophageal mucosa 24 cm from the incisors. We diagnosed it as a submucosal abscess of the esophagus and prescribed parenteral antibiotics. Submucosal abscess of the esophagus can occur even in the absence of awareness of a foreign body ingestion or oral infection. In case that the abscess was not localized clearly within the outer membrane of the esophagus, the coincidental mediastinal drainage via a cervical incision and intraoperative endoscopy seemed to be useful.

Circumferential intramural esophageal dissection with large mucosal defect

Intramural esophageal dissection (IED) is an uncommon entity characterized by mucosal rupture creating a false lumen. It usually develops following endoscopy or in old patients with bleeding tendencies and spontaneous presentation possesses diagnostic dilemma. Managing partial IED is simpler than circumferential IED. Due to rarity of presentation, management is not standardized. We report circumferential IED in a young patient and challenges faced during diagnosis and management.

Intramural Esophageal Abscess Complicated with Pleural Fistula: A Case Report

Intramural esophageal abscess is a rare entity caused by mucosal injury to the esophagus but without transmural perforation. The mucosal disruption provides access to the intraluminal infectious contents to traverse into the loose submucosal tissue, resulting in an intramural abscess. It is important to be well-versed in the clinical and imaging findings of this pathology in order to make a timely diagnosis. Here, we present a case of intramural esophageal abscess complicated with a pleural fistula with a focus on the radiological features of this rare entity. To our knowledge, this is the first time that an esophageal intramural abscess complicated with pleural fistula is discussed in peer-reviewed literature.

Management of Patients With Circumferential Intramural Esophageal Dissection

A novel minimally invasive endoscopic drainage technique using a double-tube system improves the feasibility and safety of conservative treatment in spontaneous esophageal intramural dissection (EID). Two patients with spontaneous EID underwent double-tube system placement through esophagogastroduodenoscopy. One tube was inserted into the submucosal layer with continuous suction, and another nasoduodenal tube was simultaneously inserted for enteral nutritional support. Given the ease of placement and the success of this simple double-tube system method, this technique may provide a new, low-risk, and cost-effective treatment modality for patients with EID.

Intramural oesophageal abscess: an unusual complication of tonsillitis

Tonsillitis is an extremely common condition, usually it is self-limiting, of viral origin, and managed conservatively in general practice. Rarely patients require inpatient management, usually when bacterial infection is present or when the cause is virulent organisms such as Epstein Barr virus. Complications can be divided into non-suppurative; sepsis, scarlet fever, rheumatic fever, glomerulonephritis and Lemierres disease, and suppurative; quinsy, parapharyngeal abscess and retropharyngeal abscess, respectively. Anecdotally, there is concern that modern medical practice that counsels vigilance against overuse of antibiotics, could lead to increased complications of tonsillitis. We report a case of an otherwise healthy man who presented with dysphagia, odynophagia and neck pain following a sore throat. Despite antibiotic treatment he developed an intramural oesophageal abscess, to our knowledge, an unreported complication of tonsillitis.

Spontaneous Intramural Esophageal Rupture: An Uncommon Presentation of Eosinophilic Esophagitis Requiring Endoscopic Clipping

Spontaneous intramural esophageal rupture (SIER) is a form of acute esophageal trauma defined as an injury deeper than a Mallory-Weiss tear but not extending completely through the muscular propria as in Boerhaave syndrome. SIER is a rare complication of eosinophilic esophagitis (EoE); after extensive literature review, we found 7 case reports of SIER complicating EoE. We present a case of SIER complicating EoE in a 46-year-old man with an atypical presentation requiring endoscopic clipping to achieve successful hemostasis.

Spontaneous circumferential intramural esophageal dissection complicated with esophageal perforation and esophageal-pleural fistula: a case report and literature review

Spontaneous intramural esophageal dissection (IED) is a rare disease entity. There are few reports of spontaneous IED requiring surgical treatment. Hereby, we report a 37-year-old gentleman who was diagnosed to have spontaneous extensive circumferential IED complicated with esophageal perforation, empyema, and esophageal-pleural fistula. Esophageal stenting and drainage of empyema were unsuccessful. Computed tomography and gastrografin contrast swallow demonstrated a leak to the pleural cavity, suggestive of esophageal-pleural fistula. Subsequently, a two-stage operation was performed: cervical esophagogastrostomy to bypass the perforated esophagus, followed by esophagectomy and decortication of the right lung. The patient recovered and was discharged home after a 3-week hospitalization. The management principles and recent published literature related to IED were reviewed.

Recurrent spontaneous esophageal dissection

Introduction:

Spontaneous esophageal dissection is a rare disorder of the esophagus.

Case Description:

We present what is believed to be the first reported case of recurrent esophageal dissection in a previously healthy 33-year-old man with chronic eosinophilic esophagitis. He had two episodes of spontaneous dissection of the midesophagus separated by a 5-month interval. Both episodes responded to treatment with endoscopic intervention. He has remained free of additional recurrences after definitive endoscopic therapy and oral steroid therapy. A complete description of the case, relevant radiologic imaging, and a review of the relevant literature are provided.

Discussion:

Endoscopic therapy is an option for the management of recurrent esophageal dissection.

[Management of Intramural Esophageal Dissection with Gastric Feeding Tube in an Alcoholic-hepatitis Patient]

Intramural esophageal dissection is a rare but clinically important condition in the field of gastroenterology. Classically, intramural esophageal dissection rarely occurs in patients who are anticoagulated or have poor medical condition, and its clinical presentation may include chest pain, dysphagia and hematemesis. Herein, we present a case of intramural esophageal dissection in an alcoholic hepatitis patient that was diagnosed by endoscopy and successfully treated with conservative management.

First successful treatment of a circumferential intramural esophageal dissection with perforation in a patient with eosinophilic esophagitis using a partially covered self-expandable metal stent

Intramural esophageal dissection (IED) is a rare disease characterized by a partial (PIED) or circumferential (CIED) mucosal rupture. Whereas PIED responds well to nonoperative treatment, complicated courses have been reported necessitating surgery, up to the point of esophagectomy despite complex endoscopic interventions, in CIED. We report the first case of an iatrogenic CIED with perforation in a young patient with underlying eosinophilic esophagitis treated successfully by endoscopy alone, using a partially covered self-expandable metal stent.

Spontaneous intramural full-length dissection of esophagus treated with surgical intervention: multidetector CT diagnosis with multiplanar reformations and virtual endoscopic display

Intramural esophageal dissection (IED) is an uncommon disorder characterized by separation of the mucosal and submucosal layers of the esophagus. Iatrogenic intervention is the most common cause of IED, but spontaneous dissection is rare. We report an unusually complicated case of spontaneous IED that involved the full-length of the esophagus that necessitated surgical intervention due to infection of the false lumen. In this case, chest computed tomography successfully established the diagnosis and aided in pre-operative evaluation with the use of various image post-processing techniques.

Clinical value of preventive balloon dilatation for esophageal stricture

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) were developed for the treatment of benign lesions and early superficial esophageal cancers in the gastrointestinal (GI) tract. However, esophageal strictures frequently develop in patients who undergo EMR/ESD. Therefore, we aimed to investigate the clinical value of preventive balloon dilatation (BD) for esophageal diseases following endoscopic therapy. A total of 30 patients who had received EMR or ESD were enrolled in the study. Preventive BD was carried out for 12 cases within 1 week following EMR/ESD. The remaining 18 cases were not subjected to preventive BD and were used as an historic control. The results revealed that no complications, including esophageal stenosis and dysphagia, were observed in the patients who received preventive BD. In the control group, seven cases experienced dysphagia, of which two were released without clinical treatment and the other five were released following two or three BD procedures. The results indicate that preventive BD is an effective treatment for patients with esophageal diseases following EMR and should be considered at an early stage when the mucosal injury exceeds two-thirds of the esophageal lumen.

Endoscopic submucosal dissection and surgical treatment for gastrointestinal cancer

Endoscopic submucosal dissection (ESD) is widely used in Japan as a minimally invasive treatment for early gastric cancer. The application of ESD has expanded to the esophagus and colorectum. The indication criteria for endoscopic resection (ER) are established for each organ in Japan. Additional treatment, including surgery with lymph node dissection, is recommended when pathological examinations of resected specimens do not meet the criteria. Repeat ER for locally recurrent gastrointestinal tumors may be difficult because of submucosal fibrosis, and surgical resection is required in these cases. However, ESD enables complete resection in 82%-100% of locally recurrent tumors. Transanal endoscopic microsurgery (TEM) is a well-developed surgical procedure for the local excision of rectal tumors. ESD may be superior to TEM alone for superficial rectal tumors. Perforation is a major complication of ESD, and it is traditionally treated using salvage laparotomy. However, immediate endoscopic closure followed by adequate intensive treatment may avoid the need for surgical treatment for perforations that occur during ESD. A second primary tumor in the remnant stomach after gastrectomy or a tumor in the reconstructed organ after esophageal resection has traditionally required surgical treatment because of the technical difficulty of ER. However, ESD enables complete resection in 74%-92% of these lesions. Trials of a combination of ESD and laparoscopic surgery for the resection of gastric submucosal tumors or the performance of sentinel lymph node biopsy after ESD have been reported, but the latter procedure requires a careful evaluation of its clinical feasibility.

Intramural esophageal dissection in a young man with eosinophilic esophagitis

Intramural esophageal dissection is a rare disorder that should be considered in patients presenting with chest pain, dysphagia, and hematemesis. Although most commonly occurring in elderly women with impaired coagulation, esophageal dissection has also been observed in other demographics including in those with eosinophilic esophagitis. In our report, we present the case of a 19-year-old man who was found to have an intramural esophageal dissection in the setting of undiagnosed eosinophilic esophagitis. There have been multiple, proposed management strategies; however, we implemented a nonoperative approach and obtained successful results. Intramural esophageal dissection is an important diagnosis for thoracic surgeons to be aware of as these patients often present as surgical emergencies, but often do not require an acute surgical intervention.

Intramural esophageal dissection due to pharyngeal abscess treated by endoscopic esophageal transection: a case report

Intramural esophageal dissection is a rare disorder characterized by extensive laceration between the mucosal and submucosal layers of the esophageal wall, but without perforation. The etiology of intramural dissection of the esophagus remains uncertain. Conservative management is usually considered adequate. Only one case of circumferential intramural esophageal dissection has been reported previously. We report here on a case due to an infectious cause (paryngeal abscess) that is also an unusual example of circumferential intramural esophageal dissection, which was then treated by endoscopic transection of the true internal esophageal wall and bougienage dilation.

A case of intramural oesophageal dissection secondary to nasogastric tube insertion

Intramural oesophageal dissection is a rare disorder, caused by the interposition of a divisive force between the mucosal and muscular layers of the oesophagus, leading to their separation. We present a case of intramural oesophageal dissection, secondary to the accidental iatrogenic intramural insertion of a nasogastric tube. We discuss the aetiologies, presentation, investigation and treatment of intramural oesophageal dissection, and make recommendations on the management of suspected oesophageal perforation with prophylactic nasogastric tube insertion. We also discuss other complications associated with nasogastric tube insertion, and how these may be avoided.

Circumferential mucosal dissection and esophageal perforation in a patient with eosinophilic esophagitis

A young man with a previous history of episodes of mild solid food dysphagia was admitted with a total dysphagia. The esophagogastroduodenoscopy (EGDS) showed an extensive disruption of mucosal layer with a cul-de-sac in the lower part of the esophagus. Soon after the procedure, the patient suffered from an acute chest pain and subsequent CT scan demonstrated an intramural circumferential dissection of thoracic esophagus, and a mediastinal emphysema. An emergency right thoracotomy was performed, followed by a total esophagectomy with esophagogastroplasty and jejunostomy. The histopathology confirmed that mucosal and submucosal layers were circumferentially detached from muscular wall and showed an eosinophilic infiltration of the whole organ with necrosis and erosions of mucosal, submucosal and muscular layers. The diagnosis was esophageal perforation in eosinophilic esophagitis.

Esophageal obstruction due to extensive intramural esophageal dissection: diagnosis and treatment using an endoscopic 'rendezvous' technique

Intramural esophageal dissection is an uncommon condition which usually responds to conservative management. We report an unusual case of extensive dissection resulting in complete esophageal obstruction, and which required endoscopic therapy. Diagnosis was made using two endoscopes: the transoral endoscope was in the false esophageal lumen, while a second endoscope inserted through a pre-existing gastrostomy was in the true esophageal lumen. Endoscopic needle knife incision of the entire mucosal septum resolved the patient's symptoms, and was performed without complication. The literature is reviewed for current knowledge of this condition. We also propose that 'intramural esophageal dissection' should be the preferred name for this condition, which at present is known by many names.