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

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.

Intramural dissection with mucosal rupture alleviating phlegmonous esophagitis

We report a woman presenting with unrelenting odynophagia and chest pain. Computed tomography identified a deep neck infection with acute phlegmonous esophagitis. However, esophageal intramural dissection with mucosal rupture occurred after routine nasogastric-tube insertion, and pus was vomited thereafter. The patient was treated with antibiotics and delayed endoscopic closure of the rupture site and made a full recovery. Although the definite pathogenesis remained unclear, esophageal intramural dissection with mucosal rupture, a possible and rare complication of nasogastric-tube insertion, eventually alleviated the acute phlegmonous esophagitis in our patient.

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.