Post-sclerotherapy intramural esophageal hematoma: endoscopic and radiologic findings

Intramural esophageal hematoma after elective injection sclerotherapy

CONTEXT

Although endoscopic esophageal variceal sclerotherapy has been largely supplanted by variceal band ligation, it is still performed routinely in many institutions, especially in developing countries. Intramural esophageal hematoma has been described as a rare complication of sclerotherapy. Risk factors have not been completely established.

OBJECTIVE

To demonstrate the incidence of post-sclerotherapy intramural esophageal hematoma in our hospital and discuss the possible factors involved.

METHODS

This is a retrospective observational study made at the 'Hospital Universitário Clementino Fraga Filho', Rio de Janeiro, RJ, Brazil, reviewing the medical records of all esophageal variceal sclerotherapy procedures performed from April 2000 to November 2005. The evaluation of the clinical, laboratorial and endoscopic features in our patients and those reported in the literature was also done. Review of literature was performed through MEDLINE search.

RESULTS

A total of 1,433 esophageal variceal sclerotherapy procedures were performed in 397 patients, with an intramural esophageal hematoma incidence of 4 cases (0.28%). Three of our patients developed additional complications, and one death was a direct consequence of a rupture of the hematoma. Nineteen well described cases were reported in the literature. Intramural esophageal hematoma occurred mostly after the forth esophageal variceal sclerotherapy session. Coagulation disturbances were present in the majority of cases.

CONCLUSION

Intramural esophageal hematoma is a rare complication of esophageal variceal sclerotherapy and its incidence in our institution was similar to those observed in the literature. Our study suggests that this complication occurs as a result of a fragile esophageal mucosa after previous esophageal variceal sclerotherapy sessions. Impaired coagulation, although not essential, could contribute to hematoma formation and extension through esophageal submucosa.

Esophageal hematoma

Hematoma of the esophagus is an uncommon condition. Patients often present with acute odynophagia or retrosternal pain, which may be confused with other diagnoses. We report herein two patients with esophageal hematoma caused by foreign body ingestion. Conservative treatment resulted in complete resolution. The literature is reviewed for the etiology, clinical features and management of this condition.

Incidence and management of esophageal stricture formation, ulcer bleeding, perforation, and massive hematoma formation from sclerotherapy versus band ligation

OBJECTIVES

The aim of this study was to compare the incidence and endoscopic management of esophageal stricture formation, significant ulcer bleeding, massive esophageal hematoma, and perforation resulting from endoscopic band ligation or sclerotherapy of esophageal varices.

METHODS

Consecutive esophagogastroduodenoscopies in which band ligation or sclerotherapy was performed for acute or obliterative therapy were entered into a computerized endoscopy database during a 7-yr period. Patients were excluded if they died within 72 h of treatment session from complications unrelated to the procedure. Sclerotherapy was performed using a 25-gauge needle with 1.5% sodium tetradecyl sulfate and banding was primarily performed with a Wilson-Cook 6 or 10 shooter. Complications were assessed at scheduled endoscopy and outpatient clinic visits, review of quality assurance data tallied on a monthly basis, and patient records.

RESULTS

Two hundred twenty-one cases of sclerotherapy were performed in 59 patients compared to 110 cases of band ligation in 52 patients. Five patients were excluded because of death within 72 h of the procedure. The incidence of complications from sclerotherapy:banding on a per patient basis included: esophageal stricture formation 25.6%:1.9%, ulcer bleed 25.4%:5.7%, esophageal perforation 2.2%:0%, and massive esophageal hematoma 1.6%:0%. A significant difference in complications between sclerotherapy and band ligation was noted for both stricture formation (p < 0.0005) and ulcer bleeding (p < 0.0001). The majority of ulcer bleeds required no therapeutic intervention, whereas stricture formation required multiple dilation sessions.

CONCLUSIONS

Band ligation has a significantly lower incidence of stricture formation and ulcer bleeding compared to sclerotherapy. The majority of complications can be managed with endoscopic interventions.

Management of gastrointestinal bleeding induced by gastrointestinal endoscopy

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

Spontaneous intramural haematoma of the oesophagus: a report of three cases and review of the literature

Spontaneous intramural haematoma of the oesophagus is an uncommon condition which may follow rapid increases in intra-oesophageal pressure and is predisposed to by coagulation disorders. The characteristic clinical presentation and findings at radiology and endoscopy frequently result in misdiagnosis and confusion with more sinister pathology. Awareness of the condition and conservative treatment with correction of coagulation abnormalities, when present, are the mainstays of management. Spontaneous resolution invariably occurs, and the condition is rarely fatal unless surgical treatment is attempted.