A case of intramural esophageal hematoma: complication of anticoagulation with heparin

An atypical case of fatal 'esophageal apoplexy': post-mortem findings and differential diagnosis

Forensic pathologists need to have comprehensive knowledge of a large variety of causes of sudden natural death. We describe a case of sudden and unexpected death in woman in her sixties due to rupture of a large paraesophageal hematoma. The post-mortem examination and differential diagnosis are discussed. The combined findings of whole-body post-mortem CT imaging (PMCT), targeted PMCT angiography, autopsy, and histology are most in keeping with 'esophageal apoplexy'; a rare cause of hemorrhage in the esophageal wall. A review of the literature indicates that most cases of esophageal apoplexy are self-limiting and that fatal complications are exceedingly rare. Our case demonstrates that esophageal apoplexy can present as sudden unexpected death.

Hemorrhagic shock due to submucosal esophageal hematoma along with mallory-weiss syndrome: A case report

BACKGROUND

Esophageal submucosal hematoma is a rare condition. Although the exact etiology remains uncertain, vessel fragility with external factors is believed to have led to submucosal bleeding and hematoma formation; the vessel was ruptured by a sudden increase in pressure due to nausea, and the hematoma was enlarged by antiplatelet or anticoagulant therapy. Serious conditions are rare, with a better prognosis. We present the first known case of submucosal esophageal hematoma-subsequent hemorrhagic shock due to Mallory-Weiss syndrome.

CASE SUMMARY

A 73-year-old female underwent endovascular treatment for an unruptured cerebral aneurysm. The patient received aspirin and clopidogrel before surgery and heparin during surgery, and was well during the surgery. Several hours after returning to the ICU, she complained of chest discomfort, vomited 500 mL of fresh blood, and entered hemorrhagic shock. Esophageal submucosal hematoma with Mallory-Weiss syndrome was diagnosed through an endoscopic examination and computed tomography. In addition to a massive fluid and erythrocyte transfusion, we performed a temporary compression for hemostasis with a Sengstaken-Blakemore (S-B) tube. Afterwards, she became hemodynamically stable. On postoperative day 1, we performed an upper gastrointestinal endoscopy and confirmed no expansion of the hematoma nor any recurring bleeding; therefore, we removed the S-B tube and clipped the gastric mucosal laceration at the esophagogastric junction. We started oral intake on postoperative day 10. The patient made steady progress, and was discharged on postoperative day 33.

CONCLUSION

We present the first known case of submucosal esophageal hematoma subsequent hemorrhagic shock due to Mallory-Weiss syndrome.

Intramural Esophageal Hematoma Mimicking Acute Coronary Syndrome: Complication of Warfarin Use in a Mechanical Heart Valve Patient

A 59-year-old female with a history of mitral valve replacement presented to emergency department, complaining of sudden-onset retrosternal chest pain since 4 hours ago. Electrocardiogram, laboratory tests, and computed tomography (CT) angiography of aorta were performed and ruled out aortic dissection and cardiovascular events. However, new complaint of odynophagia, dysphagia, and incidental findings in CT angiography proposed esophageal pathologies. After initial workup including upper gastrointestinal endoscopy, intramural esophageal hematoma was diagnosed. Laboratory tests revealed significant reduction in the hemoglobin level. Management of warfarin-induced major bleeding in a patient whom anticoagulation was necessary for the prevention of mechanical heart valve thrombosis was challenging. The patient recovered fully with conservative treatment and was discharged on hospital day 14 with low molecular weight heparin. We described a case of intramural esophageal hematoma as a rare condition that could be misdiagnosed as a cardiovascular emergent disease and would be worsened by antiplatelet and anticoagulation therapy. Accordingly, it is important to differentiate intramural esophageal hematoma from cardiac ischemic events. Another challenge was correction of coagulation in the presence of mechanical mitral valve. Fortunately, we had a favorable outcome following conservative management.

Computed Tomography Imaging of Iatrogenic Esophageal Injuries

ABSTRACT

Knowledge of iatrogenic esophageal injuries is important given the variety of etiologies, including medical instrumentation (eg, endoscopes), radiotherapy, and anticoagulation. The clinical presentation and imaging findings of esophageal injuries depend on the mechanism and location of the injury. Imaging modalities commonly used for the evaluation of esophageal injuries include esophagram and computed tomography. Esophageal injuries should be considered in patients with acute chest symptoms. Recognizing an unsuspected esophageal injury on imaging can be critical to reaching the correct diagnosis given their nonspecific symptomatology. This review article highlights various iatrogenic esophageal injuries and their appearance on computed tomography imaging.

The Conundrum of Treating Portal Vein Thrombosis and Submucosal Esophageal Hematoma

Submucosal esophageal hematoma (SEH) is an uncommon clinical entity and a rare form of esophageal insult. Patients usually present with retrosternal chest pain and dysphagia, which often make the diagnosis of SEH difficult as it mimics common cardiovascular and pulmonary disorders. One of the common inciting factors includes the use of anticoagulants. In this report, we discuss the case of a patient with portal vein thrombosis who was treated with heparin and consequently developed SEH.

Intramural Esophageal Hematoma Secondary to Food Ingestion

Intramural esophageal hematoma (IEH) is a rare cause of submucosal esophageal bleeding and it is on the spectrum of esophageal wall injury along with mucosal tears (Mallory-Weiss syndrome) and full thickness perforation (Boerhaave's syndrome). Its risk factors include coagulopathy, trauma (foreign body ingestion or esophageal instrumentation) or it can happen spontaneously. It presents with a triad of chest pain, dysphagia, and hematemesis; however, the triad is only present in 35% of patients. We are presenting a case of IEH secondary to food ingestion that was managed successfully by conservative measures.

Oesophageal submucosal hematoma after flow diverter embolization with favourable outcome treated by discontinuing postoperative antiplatelet therapy for only three days: a case report

Background

Oesophageal submucosal hematoma is a rare perioperative complication. When this complication develops after endovascular surgery, which requires postoperative antiplatelet therapy, whether to stop antiplatelet therapy or not is controversial. If antiplatelet therapy is discontinued, the appropriate time to resume antiplatelet therapy is unclear.

Case presentation

A 75-year-old woman (height 134 cm, weight 37 kg) underwent flow diverter embolization for unruptured cerebral aneurysm under general anaesthesia. The patient received dual antiplatelet therapy before surgery and anticoagulation therapy intraoperatively. After surgery, the patient developed hematemesis and was diagnosed with oesophageal submucosal hematoma. Conservative treatment was initiated after discontinuing antiplatelet therapy, which was resumed 3 days after surgery. The patient showed good recovery even after the resumption of antiplatelet therapy.

Conclusions

In our case, we successfully treated oesophageal submucosal hematoma developing after endovascular surgery with early resumption of postoperative antiplatelet therapy.

Esophageal submucosal hematoma developed after endovascular surgery for unruptured cerebral aneurysm under general anesthesia: a case report

Background

Esophageal submucosal hematoma is a rare complication after endovascular surgery. We report a case of an esophageal submucosal hematoma which may have been caused by rigorous cough during extubation.

Case presentation

A 75-year-old woman underwent endovascular treatment for unruptured cerebral aneurysm under general anesthesia. The patient received aspirin and clopidogrel before surgery and heparin during surgery. Activated clotting time was 316 s at the end of surgery. Protamine was not administered and continuous infusion of argatroban was started after surgery. She had a rigorous cough during removal of the tracheal tube and reported retrosternal discomfort postoperatively. She developed hemorrhagic shock after massive hematemesis. A diagnosis of esophageal submucosal hematoma was made by endoscopic examination and computed tomography. Hemostasis was achieved by compression with a Sengstaken-Blakemore tube and endoscopic cauterization. Blood pressure was recovered by blood transfusion. Endoscopic examination performed 7 days after surgery showed that esophageal submucosal hematoma had almost disappeared and slough had adhered to the mucosal laceration. The patient showed good recovery and was discharged 21 days after surgery.

Conclusions

Careful extubation and postoperative observation are required in patients receiving antiplatelet and anticoagulant therapy.

Intramural oesophageal haematoma following traumatic neck injury

This case describes a previously well 90-year-old woman who presented with neck pain, swelling, dysphagia and hoarseness following a motor vehicle collision. Oesophageal oedema was visualised on CT of cervical spine and subsequent CT angiography highlighted an actively bleeding intramural oesophageal haematoma (IOH) extending from the cervical oesophagus to the carina. This rare phenomenon (IOH) has been described as a possible consequence of blunt trauma to the neck; however, we found no cases resulting from acceleration/deceleration injury. Although this was a potentially life-threatening injury, our patient made a full recovery with conservative management.

A miniseries of spontaneous intramural esophageal hematoma in hemodialysis patients: a rare cause of dysphagia

Intramural esophageal hematoma (IEH) is an uncommon clinical condition, with a prognosis that is essentially benign. In most cases, a predisposing factor may be seen, with the most common being the history of esophagic instrumentation, food impactions, and thrombocytopenia. We report a miniseries of 3 patients on hemodialysis, who developed IEH. All 3 of them presented with sudden onset and progressively worsening dysphagia and hematemesis. Diagnosis of IEH was established by upper gastrointestinal endoscopy. All patients were managed conservatively, and symptoms of dysphagia and chest pain improved within 6-8 days. Good resolution of hematoma was noted by repeat endoscopy within 2-3 weeks. The reported case of IEH in hemodialysis patients is rare and needs to be identified early when patients present with dysphagia, as anticoagulation during hemodialysis would possibly worsen the clinical condition, the course of which is otherwise benign.

Spontaneous esophageal hematoma in a patient with atrial fibrillation

We report a case of a spontaneous esophageal hematoma in an anticoagulated patient with atrial fibrillation previously complicated by a cerebrovascular accident. A multidisciplinary discussion resulted in holding of anticoagulation until the esophageal hematoma resolved. The patient was managed nonoperatively and discharged, but returned with a new neurologic deficit 3 weeks later. Aspirin treatment was resumed. After complete resolution of hematoma on outpatient scans, warfarin treatment was restarted. The challenges of managing an esophageal hematoma in a patient requiring anticoagulation are discussed.

Intramural hematoma of the esophagus after endoscopic pinch biopsy

Intramural hematoma of the esophagus (IHE) is an uncommon form of esophageal injury, which may be an intermediate of mucosal tear (Mallory-Weiss syndrome) or transmural rupture (Boerhaave's syndrome). To date, the pathogenesis of IHE has not been well documented. IHE may occur within the submucosal layer of the esophagus following dissection of the mucosa. The most commonly presented symptoms are sudden retrosternal pain, dysphagia and hematemesis. The disorder can occur spontaneously or secondarily to trauma. In this report, we present a case of IHE which occurred after endoscopic biopsy and was recovered following conservative management in a patient who was taking long-term aspirin medication.

[A case of conservatively resolved intramural esophageal dissection combined with pneumomediastinum]

Intramural esophageal dissection (IED) is a rare form of esophageal injury. We report a rare case of spontaneous IED complicated with pneumomediastinum and successfully improved by conservative management. A 46-year-old man presented to the emergency department with chest pain and hematemesis. The endoscopic diagnosis was suspicious of IED. Chest CT scan performed to rule out complication noted IED combined with pneumomediastinum. He was managed conservatively with nil per oral, intravenous antibiotics and parenteral nutrition. Follow up study after 2 weeks later showed near complete resolution of IED. IED should be included in the differential diagnosis for unexplained acute chest pain, especially, associated with dysphagia and hematemesis. IED with pneumomediastinum or mediastinitis require prompt surgery. So far, there is no case report of IED combined with pneumomediastinum which resolved without surgical treatment. In this case, IED combined with pneumomediastinum has improved by conservative management, so we present a case report.

Intramural esophagic hematoma secondary to coumarinic anticoagulation: a case report

Esophagic Intramural Hematoma is an uncommon clinical condition, with a prognosis which is essentially benign. On most cases, a predisposing or precipitating factor may be seen, with the most common ones being the history of esophagic instrumentation, food impactations and thrombocytopenia. In the following manuscript, the authors present the case of a 54-years-old male with history of valve replacement surgery, who was treated at the Clinica Cardiovascular (Medellin, Colombia), with a clinical case of Intramural Esophagic Hematoma that was later confirmed to be due to a Coumarinic overanticoagulation. On this case, it is evidenced that Intramural Esophagic Hematoma is an unrecognized complication of Courmarinic anticoagulation therapy.

Recurrent massive bleeding due to dissecting intramural hematoma of the esophagus: Treatment with therapeutic angiography

Spontaneous or traumatic intramural bleeding of the esophagus, which is often associated with overlying mucosal dissection, constitutes a rare spectrum of esophageal injury called dissecting intramural hematoma of the esophagus (DIHE). Chest pain, swallowing difficulty, and minor hematemesis are common, which resolve spontaneously in most cases. This case report describes a patient with spontaneous DIHE with recurrent massive bleeding which required critical management and highlights a potential role for therapeutic angiography as an alternative to surgery.

Spontaneous intramural esophageal hematoma: case report and review

Intramural esophageal hematoma is a rare form of esophageal injury. The presenting symptoms are nonspecific. Esophagogastroscopy and computed tomography scan are usually needed to establish the diagnosis of intramural esophageal hematoma. Presented here is a patient with spontaneous intramural esophageal hematoma who was successfully treated with conservative measures.