Spontaneous intramural rupture of the oesophagus

Large Esophageal Intramural Hematoma After Solid Food Ingestion in a Patient Without Identifiable Inherited or Acquired Coagulopathy

We present the case of an elderly man without any significant medical history and not on any anticoagulant or antiplatelet therapy who presented with severe epigastric abdominal and substernal chest pain shortly after eating a baguette. He was found to have a large 15 cm dissecting intramural hematoma of the esophagus. He was managed conservatively with proton pump inhibitors. He remained stable throughout his hospitalization without evidence of an acute blood loss anemia and was discharged home. Repeat esophagogastroduodenoscopy 8 weeks after discharge showed a 5 mm scar with complete resolution of the dissecting intramural hematoma of the esophagus.

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.

[A Case of Intramural Hematoma of the Esophagus Mimicking Acute Coronary Syndrome]

Intramural hematoma of the esophagus is a rare condition that can be spontaneous or secondary to trauma, toxic ingestion, or intervention. If it is the spontaneous type, it usually presents initially with epigastric pain, hematemesis or dysphagia. We present a case of intramural hematoma of the esophagus mimicking acute coronary syndrome. A 63-year-old man presented with severe acute chest pain. He has four coronary stents that were inserted five years ago, from a different hospital, and is on dual antiplatelet agents. Coronary angiography was performed immediately under the suspicion of acute coronary syndrome, and we found that there was no obvious clogging of the coronary arteries. Next, chest computed tomography was performed due to suspected aortic dissection, and the result was also negative. Four days later, endoscopy was performed and intramural hematoma covered with large ulcers was diagnosed.

Esophageal Submucosal Hematoma Possibly Caused by Gastric Tube Insertion Under General Anesthesia

We present a case of an esophageal submucosal hematoma that developed after endovascular treatment for coil embolization for an unruptured cerebral aneurysm. The patient had received antiplatelet therapy before surgery and anticoagulation therapy during surgery. The orogastric tube was removed at case end with sustained negative pressure. After surgery, the patient reported chest and back pain and was diagnosed with an esophageal submucosal hematoma. The hematoma might have been related to the gastric tube insertion or removal. Providers should keep in mind the possibility of this complication when a patient who was given antithrombotic therapy reports chest or back pain after surgery.

Intramural Hematoma of the Esophagus Complicating Severe Preeclampsia

Intramural hematoma of the esophagus is a rare injury causing esophageal mucosal dissection. Forceful vomiting and coagulopathy are common underlying causes in the elderly population taking antiplatelets or anticoagulation agents. Acute retrosternal pain followed by hematemesis and dysphagia differentiates the hematoma from other cardiac or thoracic emergencies, including acute myocardial infarction or aortic dissection. Direct inspection by endoscopy is useful, but chest computed tomography best assesses the degree of obliteration of the lumen and excludes other differential diagnoses. Intramural hematoma of the esophagus is generally benign and most patients recover fully with conservative treatment. Bleeding can be managed medically unless in hemodynamically unstable patients, for whom surgical or angiographic treatment may be attempted; only rarely esophageal obstruction requires endoscopic decompression. We report an unusual case of esophageal hematoma, presenting in a young preeclamptic woman after surgical delivery of a preterm twin pregnancy, with a favorable outcome following medical management.

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.

A case of idiopathic gastroesophageal submucosal hematoma and its disappearance observed by endoscopy

A 74-year-old man was hospitalized due to hematemesis. Upper gastrointestinal endoscopy revealed a very large and dark red mass in the cardiac region of the stomach that extended from the upper esophagus. A biopsy specimen showed hemorrhagic tissue and no malignant cells. The tumor-like region ulcerated at 5 days after the administration of intravenous lansoprazole at a dose of 30 mg twice a day and resolved with scar formation at 2 months after a change to oral rabeprazole at a dose of 10 mg/day.We diagnosed the patient with gastroesophageal submucosal hematoma. Gastroesophageal submucosal hematoma is a rare complication. In this case, we could follow the process of its disappearance by endoscopy.

Outcomes following Boerhaave's syndrome

INTRODUCTION

Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit.

METHODS

Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay.

RESULTS

Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days.

CONCLUSIONS

Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

[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.

Iatrogenic esophageal submucosal dissection after attempted diagnostic gastroscopy (with videos)

Diagnostic esophagogastroduodenoscopy (EGD) is generally a very safe procedure. We report the first case of iatrogenic esophageal submucosal dissection after an attempted diagnostic gastroscopy in a patient with a small previously undiagnosed Zenker's diverticulum (ZD). After EGD, she developed severe dysphagia with the inability to swallow solids, liquids, and even her own saliva. On barium swallow study, there was a column of contrast below the upper esophageal sphincter, and this was misdiagnosed as a large ZD by the radiologist. The resultant stricture was successfully managed with endoscopic balloon dilatation under fluoroscopy with wire-guided cannulation. The ZD was treated with flexible endoscopic clip-assisted diverticulotomy. Iatrogenic submucosal dissection is a unique complication of upper endoscopy. Endoscopists, otolaryngologists, radiologists, and cardiothoracic surgeons should be aware of this condition and prepare to manage it appropriately. If the patient is stable and the possibility of perforation is small, conservative and supportive care can be tried first. A surgical gastrostomy tube can be placed for enteral feeding. In patients with ZD, ZD recognition and gentle manipulation is strongly recommended during esophageal intubation.

Spontaneous rupture of the oesophagus

BACKGROUND

The aim of this study was to evaluate the diagnosis, management and outcome of patients with spontaneous rupture of the oesophagus in a single centre.

METHODS

Between October 1993 and May 2007, 51 consecutive patients with spontaneous oesophageal rupture were evaluated with contrast radiology and flexible endoscopy. Patients with limited contamination who fulfilled specific criteria were managed by a non-operative approach, whereas the remainder underwent thoracotomy.

RESULTS

The median time to diagnosis was 24 (range 4-604) h. Initial diagnosis was by contrast swallow in 18 of 24 patients, computed tomography in 15 of 17 and endoscopy in 18 of 18. There were no deaths among 17 patients who were managed non-operatively with targeted drainage, intravenous antimicrobials, nasogastric decompression and enteral nutrition. Of 31 patients who underwent primary thoracotomy and oesophageal repair (over a Ttube in 29), 11 died in hospital. Three patients could not be resuscitated adequately and did not have surgical intervention.

CONCLUSION

Spontaneous oesophageal rupture represents a spectrum of disease. Accurate radiological and endoscopic evaluation can identify those suitable for radical non-operative treatment and those who require thoracotomy.

Esophageal laceration with intramural dissection mimics esophageal perforation

Esophageal laceration with intramural dissection is a rare type of injury but without perforation. It is difficult to differentiate from esophageal perforation at presentation time. We report the case of a 46-year-old man who was admitted to our hospital complaining of progressive chest pain, dysphagia, and odynophagia after swallowing a fish bone three days prior to admission. Esophagoscopy revealed a deep longitudinal laceration with pus discharge in the esophagus. Computed tomography of the chest revealed low posterior mediastinal abscess formation. Surgery was performed under the impression of esophageal perforation. The definite diagnosis was esophageal laceration with intramural dissection.

Intramural hematoma of the esophagus: a pictorial essay

Intramural hematoma of the esophagus (IHE) is a rare but well-documented condition that is part of the spectrum of esophageal injuries which includes the more common Mallory-Weiss tear and Boerhaave's syndrome. Acute retrosternal or epigastric pain is a common clinical feature, which can be accompanied by dysphagia, odynophagia, or hematemesis. An early differentiation from Mallory-Weiss tear, Boerhaave syndrome, ruptured aortic aneurysm, aortic dissection, acute myocardial infarction, or pulmonary pathology can be difficult. Computed tomography (CT) is the imaging modality of choice and characteristically reveals a concentric or eccentric thickening of the esophageal wall with well-defined borders and variable degree of obliteration of the lumen. Measurement of the attenuation values within the lesion will reveal blood density which varies according to the age of the hematoma. CT should be considered the preferred diagnostic technique, thereby facilitating proper clinical management. Early diagnosis is crucial as most patients may be treated conservatively with good outcome.

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.

Esophageal dissection complicating transesophageal echocardiogram--the lesson to be learned: do not force the issue

Transesophageal echocardiogram is a very safe procedure, however, it is not devoid of complications. We report a case of esophageal dissection complicating transesophageal echocardiogram in a 52-year-old man who was treated conservatively. Moreover, we review briefly the complications of transesophageal echocardiogram.

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.

Perforación intramural espontánea del esófago

Spontaneous intramural dissection of the esophagus (SIDE) is an unusual clinical entity. It is a benign disease that, despite its alarming endoscopic appearance, usually responds well to conservative management and has an excellent prognosis. Nevertheless, some situations require emergency surgical treatment. These situations include esophageal perforation with mediastinitis, massive bleeding, and abscess, among others. Upper gastrointestinal endoscopy is a useful diagnostic test when radiological examinations (hydrosoluble contrast esophagogram, computed tomography, or magnetic resonance imaging) have excluded perforation. We present the case of a 42-year-old woman who was admitted to our hospital complaining of acute chest pain, dysphagia, and odynophagia. Because of the persistence of symptoms and diagnostic uncertainty (SIDE versus complicated esophageal duplication cyst) surgery was performed. The definitive diagnosis was SIDE.

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

Spontaneous intramural esophageal dissection is a rare disorder characterized by a lengthy laceration between the mucosal and submucosal layers of the esophageal wall, without perforation. The majority of previously reported cases of spontaneous intramural esophageal dissection were partial, and the circumferential type of intramural esophageal dissection has not been reported previously. Most spontaneous intramural esophageal dissection responds to conservative management, and usually it dose not lapse into a long protracted course of dealing with sequelae. We report an unusual case of circumferential intramural esophageal dissection, in which initial conservative management failed to alleviate the patient's dysphagia, necessitating the use of several endoscopic treatments, including incision of the septum between the false and true lumens, transection of the true esophageal wall, balloon dilatation, and metal stent insertion.

Transient esophageal obstruction in a young man: an intramural esophageal hematoma?

SUMMARY. We present a case of a 20-year-old, previously healthy, male student who presented with dysphagia secondary to mechanical esophageal obstruction that resolved spontaneously. Although our patient did not have 'classic' patient characteristics, we believe that the clinical evidence supports the conclusion that our patient was an atypical presentation of intramural esophageal hematoma.

Oesophageal dissection: contrast studies and CT in diagnosis and monitoring

Oesophageal dissection with intramural haematoma formation can be difficult to diagnose. Endoscopy can be diagnostic, but imaging techniques including computed tomography and contrast swallows can both accurately demonstrate a dissection and exclude many other pathologies. A case utilizing both imaging modalities to diagnose and monitor the condition in a patient with a bleeding disorder is presented.

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 hematoma localized in the proximal esophagus: truly "spontaneous"?

After a usual meal, a 57-year-old woman with normal hemostasis experienced a hematoemesis. She was then diagnosed endoscopically as having an intramural hematoma of the esophagus, which ranged from 18 cm to 24 cm from the incisors. The hematoma is considered to have developed not "spontaneously" but as a result of direct abrasive trauma by foodstuffs. The authors think it appropriate to use the term "spontaneous" only when the development of hematoma is unrelated to emetogenic events, impaired hemostasis, and food-induced injury.

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.

Acute submucosal esophageal hemorrhage

Two cases of acute submucosal esophageal hemorrhage are reported. This condition is uncommon and presents an urgent diagnostic dilemma. Its presentation, diagnosis, and management are reviewed. The underlying pathology and causative factors are researched and clarified. Conservative management is safe and effective.

Intramural esophageal dissection

A case of intramural esophageal dissection is reported and the literature reviewed. Patients with intramural esophageal dissection are usually women in their seventh or eighth decade. The most common presenting symptoms are chest pain, dysphagia, and hematemesis. The diagnosis is made by contrast esophagography, esophagoscopy, or both. Nonoperative therapy has proved to be uniformly successful.

Intramural hematoma of the esophagus: appearance on magnetic resonance imaging

A 73-yr-old woman on anticoagulant therapy experienced progressive dyspnea and dysphagia due to a large compressing mass in the posterior mediastinum. Because her clinical condition deteriorated rapidly surgery was performed. A large intramural hematoma along the full length of the esophagus with dissection of the muscular layers of the esophagus was found. MRI findings of this case are reported.

Esophageal hematoma and tear requiring emergency surgical intervention. A case report and literature review

Esophageal hematoma is a disorder characterized by the sudden development of pain, hematemesis, or dysphagia, commonly with minimal precipitant. We present the case of 59-year-old man with esophageal hematoma, precipitated by eating, with massive hematemesis requiring surgical intervention. A review of 31 additional cases in the literature since 1980 is discussed. The Mallory-Weiss syndrome and Boerhaave syndrome are distinct entities with some clinical similarities.