Ann Thorac Surg 2004;78:343-345
© 2004 The Society of Thoracic Surgeons
Case report
Spontaneous intramural esophageal hematoma
Ming Shian Lu, MDa,
Yun Hen Liu, MDa,
Hui Ping Liu, MDa,
Yi Cheng Wu, MDa,
YinYi Chu, MDb,
Jaw Ji Chu, MDa*
a Divisions of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kweishan, Taoyuan, Taiwan
b Gastroenterology, Chang Gung Memorial Hospital, Chang Gung University, Kweishan, Taoyuan, Taiwan
Accepted for publication June 13, 2003.
* Address reprint requests to Dr Jaw Ji Chu, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsing St, Kweishan, Taoyuan, Taiwan 333
e-mail: jjc1015{at}cgmh.org.tw
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Abstract
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Spontaneous intramural esophageal hematoma is a rare cause of chest pain. Erroneous diagnosis may cause inappropriate management and disaster. We describe one case of spontaneous intramural hematoma that was successfully managed by conservative treatment. Endoscopic and radiographic images are reviewed. The benefit of endoscopic ultrasound is emphasized.
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Introduction
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Spontaneous intramural esophageal hematoma is a rare cause of chest pain. The majority of cases of intramural esophageal hematoma have predisposing factors such as coagulopathy [1, 2], instrumentation [3], trauma [4], or foreign body ingestion [5]. Because of its benign course, the diagnosis of spontaneous intramural esophageal hematoma is usually delayed until other more serious conditions have been excluded. We present a case of acute chest pain subsequently diagnosed as spontaneous intramural esophageal hematoma.
A 37-year-old man presented to our emergency department with the sudden onset of acute chest pain, dysphagia, and odynophagia for 2 days. He had a long history of uncontrolled hypertension and hyperuricemia. No antecedent of trauma was recalled.
The man visited local clinics 1 day before admission, with severe chest pain, high blood pressure (systolic blood pressure > 220 mm Hg, diastolic blood pressure > 130 mm Hg), and a huge esophageal hematoma on panendoscopic examination. He was referred to us with a diagnosis of dissecting thoracic aorta rupture into the esophagus. On arrival at our emergency department, the patient was distressed by persistent chest pain and hypertension (160/110 mm Hg). Laboratory results revealed a hemoglobin level of 12.7 g/dL, a platelet count of 268,000/mL, and prothrombin time of 10.9 seconds. A thoracic computed tomographic scan revealed a slightly hyperdense longitudinal mass adjacent to the middle and lower esophagus, from the carina to the gastroesophageal junction. It measured 3 to 4 cm in its cross dimension and 11.5 cm in longitudinal length. There was a crescentic soft-tissue density encircling the thoracic aorta but no evidence of aortic intimal flap or aortic dissection (Fig 1).
A barium swallow showed a filling defect over the middle and lower esophagus. An aortogram showed displacement of the descending aorta to the left but no evidence of contrast leakage or false aortic lumen. Because of concern about the rupture of the aorta or aortoesophageal fistula, an endoscopic sonogram (endoscopic ultrasound) was performed. A mixed echoic and partial liquefied lesion was noted over the submucosal layer, without attachment to the aortic adventitia (Figs 2, 3).
On the basis of these studies, a diagnosis of spontaneous intramural esophageal hematoma was made. The patient was managed conservatively with oral analgesics and antihypertensive treatment. The symptoms subsided over a few days. One week later, endoscopy revealed the resorption of the intramural hematoma and the healing of the esophageal ulcer. The patient was discharged on a soft diet. Endoscopic ultrasound 1 month later revealed the complete resolution of the submucosal hematoma, without thickening of the esophageal wall. The patient was asymptomatic and in good health.
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Fig 2. Endoscopic ultrasound showing a mixed echoic and partial liquefied lesion over the submucosal layer, without attachment to the aorta adventitia.
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Fig 3. Endoscopy at 14 days showing resolution of the hematoma and linear ulcer over the middle and lower esophagus.
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Comment
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Esophageal hematoma is a rare condition associated with the dissection of the mucosa from the muscular layer. The most common predisposing factors for esophageal hematoma are esophageal instrumentation, hematologic or bleeding disorders, and anticoagulation therapy [6]. Other less frequent causes reported include food impaction, pill ingestion, and trauma.
Symptoms include retrosternal chest pain, dysphagia, and hematemesis. Thirty-five percent of patients present with this triad, and half present with at least two symptoms. Careful histories and appropriate investigations allow for correct diagnoses and can differentiate the condition from Mallory-Weiss syndrome, Boerhaave syndrome, thoracic aorta dissection, and acute myocardial infarction.
Endoscopic examination revealed a characteristic large longitudinal hematoma. Barium esophagogram findings included intraluminal narrowing and a filling defect of the esophagus. Computed tomographic images revealed a mass confined to the esophageal lumen that did not enhance with the injection of contrast medium. Endoscopic ultrasonography can be useful for excluding malignant lesions and aortic dissection. A hypoechoic esophageal lesion confined within the esophageal wall and distinct from the aorta adventitia is pathognomonic [7].
The prognosis of intramural hematoma is good. Conservative and supportive care remains the main therapeutic modality, and most hematomas resolve spontaneously. In contrast, aortoesophageal fistula is a life-threatening disease that may present as submucosal hematoma, with a very poor prognosis if surgical intervention is delayed. Physicians should be aware of and differentiate aortoesophageal fistula from intramural hematoma. The classic endoscopic finding of aortoesophageal fistula is a pulsatile esophageal mass. Computed tomography and ultrasonography may reveal an intimal flap or a communication between the esophagus and the aorta [8]. In our patient, the precise diagnosis was achieved after endoscopic ultrasound. It demonstrated that the periesophageal lesion was confined in the submucosal layer, without communication to the aorta. Spontaneous intramural esophageal hematoma is a rare entity. Its diagnosis is difficult, especially in patients without obvious predisposing factors. Differential diagnosis between spontaneous intramural esophageal hematoma and aortoesophageal fistula is crucial. Endoscopic ultrasonography is a useful supplementary study. Once a diagnosis is confirmed, treatment is conservative, and long-term results are good.
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References
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Spontaneous intramural oesophageal haematoma: an unusual cause of chest pain
BMJ Case Reports,
November 15, 2011;
2011(nov11_1):
bcr0920114837 - bcr0920114837.
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Abstract
Introduction
