The spectrum of emetogenic injury to the esophagus and stomach

Life-threatening bleeding from dissecting Intramural Hematoma of Esophagus (IHE) treated by trans arterial embolization

Dissecting intramural hematoma of esophagus (DIHE) is an uncommon entity, characterized by accumulation of blood within the esophageal wall and usually managed conservatively. Only in rare circumstances, DIHE is associated with massive life-threatening hemorrhage requiring emergency treatment. We present a case of DIHE associated with cardiovascular collapse and treated by transcatheter arterial embolization. Transcatheter arterial embolization is a rare treatment option for DIHE associated with hemodynamic instability and only a handful of cases have been reported in the literature.

Boerhaave syndrome due to excessive alcohol consumption: two case reports

BACKGROUND

Spontaneous esophageal rupture, or Boerhaave syndrome, is a fatal disorder caused by an elevated esophageal pressure owing to forceful vomiting. Patients with Boerhaave syndrome often present with chest pain, dyspnea, and shock. We report on two patients of Boerhaave syndrome with different severities that was triggered by excessive alcohol consumption and was diagnosed immediately in the emergency room.

CASE PRESENTATION

The patient in case 1 complained of severe chest pain and nausea and vomited on arrival at the hospital. He was subsequently diagnosed with Boerhaave syndrome coupled with mediastinitis using computed tomography (CT) and esophagogram. An emergency operation was successfully performed, in which a 3-cm tear was found on the left posterior wall of the distal esophagus. The patient subsequently had anastomotic leakage but was discharged 41 days later. The patient in case 2 complained of severe chest pain, nausea, vomiting, and hematemesis on arrival. He was suggested of having Boerhaave syndrome without mediastinitis on CT. The symptoms gradually disappeared after conservative treatment. Upper gastrointestinal endoscopy performed on the ninth day revealed a scar on the left wall of the distal esophagus. The patient was discharged 11 days later. In addition to the varying severity between the cases, the patient in case 2 was initially considered to have Mallory-Weiss syndrome.

CONCLUSION

Owing to similar histories and symptoms, Boerhaave syndrome and Mallory-Weiss syndrome must be accurately distinguished by emergency clinicians. CT can be a useful modality to detect any severity of Boerhaave syndrome and also offers the possibility to distinguish Boerhaave syndrome from Mallory-Weiss syndrome.

Use of propofol versus propofol combined with fentanyl during painless gastroscopy in elderly patients

AIM: To assess the advantages and disadvantages of two intravenous anesthesia strategies used for painless gastroscopy in elderly patients.

METHODS: Sixty elderly patients who underwent gastroscopy at our hospital from May 2008 to February 2011 were included. The patients were randomly and equally divided into two groups (A and B) and underwent treatment with either intravenous propofol or propofol combined with fentanyl. The OAAS criteria were adopted, and a score < 2 was used as the critical value. Those who did not reach the critical value were additionally given propofol 10-30 mg. The time required for reaching the critical value, recovery time, and orientation recovery time were compared. Using the time point at 20 min prior to anesthesia as the basic point, the heart rate (HR), blood pressure (BP), respiratory rate (RR), and SPO₂ at 5 min after anesthesia were compared.

RESULTS: All the 60 patients felt asleep and completed gastroscopy. 46 cases waked up 1-5 min after gastroscopy, and 14 cases became completely conscious in 15 min. Both the time of reaching the critical value and analepsia in group A were significantly lower than those in group B (19.5 min ± 2.6 min vs 14.9 min ± 3.1 min, 17.5 min ± 2.2 min vs 11.1 min ± 1.7 min, both P < 0.01). The orientation recovery time did not significantly differed between the two groups (P > 0.05). HR, BP, RR, and SPO₂ were all decreased to some extent in both groups in the first 5 min. The decreasing amplitude of HR in group A was significantly higher than that in group B (-9.9 time/min ± 5.1 time/min vs -13.2 time/min ± 4.7 time/min, P < 0.05), but the decreasing amplitude of systolic pressure was significantly lower in group A than in group B (P < 0.01). The decreasing amplitude of RR and SPO₂ showed no significant difference between the two groups (both P > 0.05).

CONCLUSION: Intravenous propofol combined with fentanyl is an effective and safe anesthesia method in painless endoscopy in elderly patients, with less stimulation of pharyngeal reflex and less effect on the circulatory and respiratory systems.

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.

Endoscopic incision of a septum in a case of spontaneous intramural dissection of the esophagus

Intramural dissection of the esophagus is a rare esophageal disorder that is characterized by a long laceration between the esophageal mucosa and submucosa but without perforation. It reveals characteristic radiologic and endoscopic features. The etiology of intramural dissection of the esophagus remains uncertain. The most common presenting symptoms are sudden retrosternal pain, hematemesis, odynophagia, dysphagia, and back pain. Conservative management is usually thought to be adequate. We report a case of spontaneous intramural esophageal dissection, in which the symptom of dysphagia did not improve with the conservative management, and an endoscopic incision of the septum between true and false lumens using a needle-type diathermy knife was done safely and effectively.

Spontaneous intramural hematoma of the esophagus

Spontaneous intramural hematoma of the esophagus (SIHE) is a rare condition, usually presenting with severe acute chest pain. Vomiting, dysphagia, odynophagia, and hematemesis may appear later. We herein report a case of this disease in a patient treated with low doses of aspirin, and review the literature for possible etiologies for this condition. In addition, we compare the utility of the various diagnostic modalities in this uncommon condition.

Spontaneous intramural haematoma of the oesophagus: CT and MRI appearances

A 64-year-old man with history of ischaemic heart disease and coronary artery bypass graft surgery, but no history of peptic ulcer or liver disease, presented with retrosternal pain and coffee-ground vomitus. Endoscopy revealed a long column of bluish discolouration with normal mucosa interpreted as a grade IV oesophageal varix. Computed tomography showed a non-enhancing low-density submucosal columnar lesion in the mid- and lower oesophagus consistent with a submucosal haematoma. This resolved on follow-up at 10 days. The magnetic resonance features of intermediate signal intensity on T1-weighted images and hyperintense signal on T2-weighted images of this lesion are also highlighted.

A case of spontaneous intramural hematoma of the esophagus

The authors experienced a case of spontaneous intramural hematoma of the esophagus (SIHE). This 44-year-old Japanese woman was admitted to our hospital because of chest pain accompanied by minimal hematemesis. Endoscopy revealed an elevated intraluminal bleeding bulge. Barium esophagograms showed a smooth and giant elevated intraluminal lesion. CT and MRI also revealed thickening of the esophageal wall. Fasting and intravenous hyperalimentation were prescribed on admission. The conditions improved and she became asymptomatic on the fifth day of hospitalization. Subsequent examinations by esophagography and endoscopy showed that the elevated lesion had disappeared and that the inflamed mucosal lesion had improved. The prognosis of cases of SIHE is excellent under conservative therapy, but close follow-up care is necessary.

Esophageal apoplexy: case report, review, and comparison with other esophageal disorders

Esophageal injuries are potentially serious disorders requiring prompt recognition and management. In addition to the well-recognized Mallory-Weiss and Boerhaave's syndromes, there exists a condition of spontaneous intramural esophageal hemorrhage: esophageal apoplexy. A case of esophageal apoplexy is presented as well as an evaluation of clinical presentations based on a collected review of the 66 cases previously reported. In addition, esophageal apoplexy is contrasted with the Mallory-Weiss and Boerhaave's syndromes, focusing on distinguishing attributes of utility to the emergency practitioner.

Intramural oesophageal dissection

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Spontaneous intramural rupture of the oesophagus

The clinical, endoscopic, and radiological features of seven patients with an uncommon oesophageal injury characterised by long lacerations of the oesophageal mucosa with haematoma formation but without perforation are reported. The injuries were not related to forceful vomiting or any other definable cause but were similar to those previously described as intramural oesophageal rupture. Upper gastrointestinal endoscopy undertaken to identify the cause of haematemesis in six patients proved safe and useful. When dysphagia and odynophagia occurred early in the clinical course to alert the clinician to possible oesophageal injury, radiological contrast studies were used to exclude perforation. One patient in this study had oesophageal cavernocapillary haemangiomatosis which may have caused intramural oesophageal bleeding and submucosal dissection but in the remainder the aetiology of intramural oesophageal rupture remains uncertain. Conservative management was successful in all patients.

Intramural haematoma of the oesophagus complicated by perforation

A case is presented where spontaneous bleeding into the wall of the oesophagus was exacerbated by anticoagulant therapy. Subsequently, iatrogenic, full-thickness perforation of the oesophagus occurred during endoscopy and, ultimately, oesophagectomy was required. If this condition is suspected on clinical grounds, the most appropriate sequence of investigations would appear to be contrast radiography in the first instance with cautious use of oesophagoscopy.

Spontaneous intramural oesophageal dissection

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Intramural hematoma of the esophagus: unusual complication of variceal sclerotherapy

A patient is described who developed severe retrosternal pain and dysphagia immediately after sclerotherapy of esophageal varices. Extensive submucosal bleeding of the esophageal wall was demonstrated radiologically and endoscopically. This lesion resolved within 2 weeks of conservative treatment.

Linear ulcers of the greater curvature of the stomach in patients with mucosal pyloric stenosis

Two patients with linear ulcers of the greater curvature of the stomach are reported. These patients formed part of a series of 18 patients with mucosal pyloric stenosis seen between 1963 and 1981. The mechanisms that may be important in the pathogenesis of these unusual ulcers are discussed.

Obstructing esophageal hematoma mimicking cancer: a case report and experimental study

In this paper the 10th case of esophageal hematoma, a rare variant of the Mallory-Weiss syndrome, is reported. The radiographic study strongly suggested an obstructing neoplasm, however, this hematoma disappeared within five days and this same rapid disappearance was noted in dogs in which esophageal hematomas were induced. Fiberoptic esophagoscopy provides a clue to the diagnosis since the mural hematoma is differentiated from carcinoma by its dark color.

Esophageal hematoma. Four new cases, a review, and proposed etiology

We report four cases of esophageal hematoma and emphasize that endoscopically and radiographically it may simulate a neoplasm. After a review of 26 cases, we found that patients with normal hemostasis often had esophageal hematoma occur distally after vomiting. Most of these hematomas probably originated from a Mallory-Weiss laceration. In contrast, patients with impaired hemostasis had esophageal hematoma occur proximally or at multiple sites. Many of these hematomas occurred spontaneously, without a history of vomiting, and probably resulted from impaired coagulation. Regardless of etiology most esophageal hematomas were associated with a benign course.

Spontaneous intramural rupture and intramural haematoma of the oesophagus

Spontaneous intramural rupture or intramural haematoma of the oesophagus is a rare cause of acute pain in the chest and upper abdomen. Much less ominous than spontaneous complete rupture from which it must be distinguished, it seldom if ever necessitates operation. Five new cases are described and reviewed together with 15 collected from published reports. The dominant symptom of every case was severe and constant retrosternal or epigastric pain; concomitant dysphagia was mentioned in 11 cases. In seven the pain was preceded by or coincided with vomiting. The condition was related to other stresses in three and appeared to be truly spontaneous in 10. In approximately one-third of cases it started suddenly but more often it began as discomfort worsening rapidly. Fourteen patients vomited blood after experiencing pain but only four were given transfusions. In contradistinction to complete rupture, none had surgical emphysema and plain chest radiographs were unremarkable. All had abnormal gastrografin or barium swallows. Intramural haematomas with or without mucosal tears were seen in the 11 cases in which oesophagoscopy was performed. Fifteen patients made rapid and complete recoveries on conservative management. Of the four who did not respond satisfactorily, one had the oesophagus repaired, two had drainage of the mediastinum after failure to find the false lumen at thoracotomy, and one had only an abdominal exploration. The only death in the whole series occurred after a disastrous emergency exploration and subsequent total oesophagectomy.

Spontaneous closure of esophageal tear in Boerhaave's syndrome

An unusual case of spontaneous rupture of the esophagus is reported in which the patient survived without surgical closure or drainage procedure. The site of perforation and subsequent closure are documented radiologically.

Trauma to the esophagus

We have classified esophageal trauma into three major categories: (1) Iatrogenic trauma including endoscopic perforation, trauma due to dilatation, surgical trauma, tube trauma, radiation trauma, and drug trauma; (2) Self-induced trauma including foreign bodies, corrosive or drug ingestion, and postemetic trauma; (3) Direct trauma including penetrating trauma and blunt trauma. Discussion and illustrative cases are presented.

Postemetic hematomas: a variant of the Mallory-Weiss syndrome

Of forty-four patients with the Mallory-Weiss syndrome, nine (20 per cent) had endoscopic evidence of small submucosal hematoma(s) lying in or adjacent to the region of the the tear. These small hematomas are believed to occur most commonly as a variant of the Mallory-Weiss lesion.

Boerhaave's syndrome: The importance of early diagnosis and treatment

Boerhaave's syndrome, spontaneous esophageal rupture, is associated with a 70% survival with surgical intervention. Mortality and morbidity are increased in direct proportion to the time between diagnosis and appropriate surgical intervention. Sepsis, hypovolemia and shock are the predominant causes of morbidity and mortality in Boerhaave's syndrome. Two cases of Boerhaave's syndrome are presented which were diagnosed rapidly, and were managed surgically, resulting in survival of the patients. A review of the literature is also presented with emphasis on the clinical and roentgenologic methods of diagnosis of spontaneous esophageal rupture. Particular attention is given to the fact that early diagnosis and treatment will unquestionably reduce the morbidity of this syndrome.

Intramural rupture of the oesophagus

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