Spontaneous intramural rupture and intramural haematoma of the oesophagus

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 Dissection: A Rare Cause of Acute Chest Pain after Percutaneous Coronary Intervention

Intramural esophageal dissection is a condition that typically presents with chest pains and may be associated with hematemesis, odynophagia, and hematemesis. The role of antiplatelet/anticoagulant agents in the development of intramural esophageal hematoma is controversial. The management of intramural esophageal dissection is generally conservative with low mortality and morbidity. The case described here is a 66-year-old woman who presented with chest pains, odynophagia, and dysphagia 1 month after percutaneous coronary intervention while taking ASA (80 mg daily) and clopidogrel (75 mg daily) for dual antiplatelet therapy. The patient was diagnosed as intramural esophageal dissection and underwent successful conservative medical management. The relative contribution of dual antiplatelet therapy with ASA and clopidogrel after percutaneous coronary intervention in this case is, albeit uncertain, a possibility.

Spontaneous circumferential intramural esophageal dissection complicated with esophageal perforation and esophageal-pleural fistula: a case report and literature review

Spontaneous intramural esophageal dissection (IED) is a rare disease entity. There are few reports of spontaneous IED requiring surgical treatment. Hereby, we report a 37-year-old gentleman who was diagnosed to have spontaneous extensive circumferential IED complicated with esophageal perforation, empyema, and esophageal-pleural fistula. Esophageal stenting and drainage of empyema were unsuccessful. Computed tomography and gastrografin contrast swallow demonstrated a leak to the pleural cavity, suggestive of esophageal-pleural fistula. Subsequently, a two-stage operation was performed: cervical esophagogastrostomy to bypass the perforated esophagus, followed by esophagectomy and decortication of the right lung. The patient recovered and was discharged home after a 3-week hospitalization. The management principles and recent published literature related to IED were reviewed.

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.

Dissecting intramural hematoma of esophagus after thrombolytic therapy: a case report

Esophageal hematoma is a relatively rare event. We report a case of severe chest pain associated with myocardial infarction and recurrent chest pain after administration of a thrombolytic agent. The chest pain was different from the presenting symptom and accompanied by 2 episodes of hematemesis. Esophageal hematoma was confirmed after endoscopy and computed tomography. Esophageal hematoma is a relatively rare event after thrombolytic therapy.

A rare cause for acute chest pain in the emergency setting that is hard to swallow

Intramural esophageal hematoma is a very rare but important cause of chest pain. This condition shares similarity with the diagnosis of other thoracic emergencies and has a high potential for misdiagnosis. The emergency clinician plays a critical role in the early identification and management of these patients. The management of intramural hematomas is typically conservative, and a misdiagnosis could lead to deleterious effects. Preexisting coagulopathy is one of the major risk factors. With the advent of new anticoagulation medications to prevent thromboembolic events, it is important that emergency medicine providers expand the differential diagnosis of chest pain.

Sudden death due to a dissecting intramural hematoma of the esophagus (DIHE) in a woman with severe neurofibromatosis-related scoliosis

Dissecting intramural hematoma of the esophagus (DIHE) is a rare condition in which intramural hemorrhage can lead to submucosal dissection of the esophageal wall. DIHE is generally considered a benign disease, and the only mortality associated with DIHE has been due to operative intervention or to the presence of another underlying, life-threatening condition. We report, however, a case of sudden death due to the spontaneous rupture of a DIHE that occurred in a 32-year-old woman, affected by neurofibromatosis type 1. She was admitted to the local emergency room, presenting a 24-hour history of sudden onset, severe central chest and interscapular pain associated with dysphagia, odynophagia and vomiting. Her condition worsened and proved fatal within a 6-hour period. A complete autopsy was then conducted, showing a complete dissecting intramural hematoma with laceration of the third superior of the esophagus. We can hypothesize that abnormal variations of gastro-esophageal pressure during ingurgitation and during bolus movement could be predisposing factors in the pathogenesis of the dissection. On the other hand angular kyphoscoliosis deformity may have had play a role as precipitating factor while vomiting in the subject's medical history can then be interpreted as the likely activation phenomenon.

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.

Achalasia combined with esophageal intramural hematoma: Case report and literature review

A 62-year-old male patient was admitted to our hospital due to severe chest pain, odynophagia, and hematemesis. Chest computed tomography showed an esophageal submucosal tumor. Esophagogastroduodenoscopy (EGD) revealed a longitudinal purplish bulging tumor of the esophagus. Endoscopic ultrasound (EUS) showed a mixed echoic tumor with partial liquefaction from the submucosal layer. The patient was diagnosed with esophageal intramural hematoma as well as achalasia by upper gastrointestinal endoscopy, esophagography and esophageal manometry. The patient was managed conservatively with intravenous nutrition, and oral feeding was discontinued. Follow-up EGD and EUS showed complete recovery of the esophageal wall, and finally, the patient underwent endoscopic dilatation for achalasia. The patient was symptom free at the time when we wrote this manuscript.

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 esophageal injury: esophageal intramural hematoma

Acute chest pain can indicate a life-threatening condition and it is important for physicians to diagnose and treat it as a matter of urgency. We report 1 rare case of esophageal intramural hematoma (IMH) that presented with chest pain at the emergency department and which was initially clinically suspected to be due to aortic dissection. The case was diagnosed preoperatively by multidetector computed tomography. Esophageal IMH may represent an intermediate stage between Mallory-Weiss tear (mucosal) and Boerhaave's syndrome (transmural). Multidetector computed tomography is a useful noninvasive imaging modality for accurate diagnosis of these spontaneous intramural and transmural ruptures of the esophagus, and aids in the differential diagnosis of aortic and other mediastinal diseases with acute chest pain.

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 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.

Spontaneous intramural esophageal hematoma

We report the case of an 80-year-old woman who developed a spontaneous intramural esophageal hematoma and review the available literature. Spontaneous intramural esophageal hematoma (SIOH) is a rare but important condition. Because the cardinal symptom is severe chest pain, the condition is often initially misdiagnosed as an acute cardiac event or aortic dissection. Increased awareness of SIOH may prevent misdiagnosis on the basis of endoscopic and radiological appearances.

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.

The spectrum of spontaneous and iatrogenic esophageal injury: perforations, Mallory-Weiss tears, and hematomas

Esophageal perforations, Mallory-Weiss tears, and esophageal hematoma involve traumatic injury to the esophagus. These can be iatrogenic, in particular due to esophageal instrumentation, but can also occur spontaneously. The remarkable increase in diagnostic and therapeutic endoscopy as well as esophageal surgery has made instrumentation the most common cause of esophageal perforation. In many instances, spontaneous perforations are associated with retching and vomiting, which causes a sudden increase in intraesophageal pressure. A high index of suspicion leading to rapid diagnosis and appropriate therapy are needed to optimize clinical outcomes. This article focuses on esophageal perforations, Mallory-Weiss tears, and esophageal hematomas, with emphasis on etiology, pathogenesis, clinical presentation, diagnosis, management, and prevention.

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.

Haematemesis and chest pain in a middle-aged women

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Esophagogastric hematoma mimicking a malignant neoplasm: clinical manifestations, diagnosis, and treatment

Esophagogastric hematoma is a rare condition occurring spontaneously or after esophageal instrumentation. In this report, we describe a patient with acute dysphagia in whom a lower esophageal mass was detected radiographically. Upper endoscopy revealed an esophageal mass that extended from the mid-esophagus to the gastroesophageal junction and was associated with a malignant-appearing ulcerated mass (5 to 6 cm) in the cardia. Gastric cancer with esophageal extension was the presumptive diagnosis. Computed tomography showed that the esophageal mass had a density similar to blood, a finding suggesting the presence of an esophageal hematoma. Biopsy specimens of the ulcer revealed acute inflammation but no malignant involvement. The patient was treated conservatively, and the initial symptoms resolved. Esophagogastric hematomas can mimic a neoplasm; thus, establishing the correct diagnosis is important because this condition has a favorable prognosis, and only conservative treatment is needed.

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.

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.

Spontaneous oesophageal haematoma: a review of the difficult diagnosis

Three cases of spontaneous oesophageal haematoma are described, with particular emphasis on their confusing clinical presentation. CT scanning was found to be helpful in making a correct diagnosis. This led to conservative treatment and ultimate full recovery.

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 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.

Dissection of the esophagus after dilatation of a cervical diaphragm

The authors report a case of a very large esophageal mucosal dissection observed during an esophagoscopy performed 7 days after dilatation of a cervical esophageal web. They treated this dissection by positioning an endoesophageal balloon which obtained the fast, overlapping closure of the torn mucosal layers and at the same time allowed both gastric drainage and enteral feeding via a pump.

Intramural hematoma of the esophagus caused by minor head injury 6 hours previously

The diagnosis of extensive intramural hematoma of the esophagus due to a bicycle trauma was considerably delayed because symptoms did not develop until 6 h after the accident. This report underscores the importance of a barium meal and computed tomographic (CT) scan in cases of unexplained chest pain, even after minor trauma.

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.

Spontaneous intramural oesophageal haematoma

Six cases of spontaneous submucosal dissection of the oesophagus are described. This rare entity should be considered in patients presenting with chest pain, usually of sudden onset, associated with dysphagia and haematemesis. Barium swallow or endoscopy are needed to confirm the diagnosis and the characteristic features are described.

Oesophageal haematoma: report of three cases

Three cases of intramural haematoma of the oesophagus are reported. Two cases mimicked benign neoplasms of the distal oesophagus. One of these resembled a polypoid tumour; the other occurred in a patient with known achalasia. Two cases presented with chest pain and haematemesis, the third presented with dysphagia and odynophagia only. One case was truly spontaneous and two cases were thought to be secondary to trauma from food.

[Spontaneous rupture of the esophagus]

Eighteen patients (16 men and two women), aged 20 to 77 years, were admitted to the University hospital between 1973 and 1984 for a Boerhaave's syndrome. Fourteen over eighteen were more than forty years old. Other particular features were the frequency of alcoholism (11 patients) and the lack of preexisting gastrointestinal symptomatology. The cardinal symptom, pain, occurred in 17 cases. It was preceded in 10 subjects by vomiting. Subcutaneous emphysema was only found in five patients, but standard chest X-ray showed seven times a pneumomediastinum. Pleural effusion was present in 14 subjects. Thirteen patients underwent thoracotomy: five within 48 h (1 death) and eight after 48 h (4 deaths); two further deaths were due to withholding surgery, and a third by performing bipolar oesophageal exclusion at a late stage (8th day); six of these deaths were related to local infection. The clinical and radiological features of Boerhaave's syndrome are presented in a review of the literature; particular attention is paid to the various methods of treatment.

Intramural rupture and intramural haematoma of the oesophagus

We report on two cases of spontaneous intramural rupture and haematoma formation in the oesophagus. This is an unusual and often misdiagnosed condition. Its diagnosis relies on the history and a barium swallow. Instrumentation can result in further damage to the oesophagus and should be avoided. Treatment is conservative and results in resolution of the haematoma and a return to normal swallowing.

Spontaneous intramural oesophageal dissection

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