AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Esophageal hematoma is a rare condition that can be spontaneous or secondary to trauma, toxic ingestion, or medical intervention.

Marks and Keet reported a case of a spontaneous intramural hematoma of the esophagus in 1968. This uncommon condition has now been well documented in the literature.

Pathophysiology

Vomiting can lead to increased intraesophageal pressure that may result in mucosal tears (Mallory-Weiss syndrome), transmural perforation (Boerhaave syndrome), or intramural hematoma of the esophagus. The hemorrhage occurs within submucosal tissues.

Intrinsic esophageal disease, such as achalasia, is rare in patients with esophageal hematoma.

Esophageal hematoma may occur at various sites of the esophagus. The mechanism producing the hematoma may determine the site. For example, a hematoma from vomiting would be in the region of the esophagogastric junction, and a hematoma from a caustic substance might be at points of narrowing.

Mortality/Morbidity

• If the hematoma is associated with a perforation of the esophagus, septic complications (eg, mediastinitis, abscess formation) are likely to occur.
• The mortality rate associated with esophageal perforations is about 10-20%.

Sex

Approximately 80% of intramural hematomas occur in women.

Age

Primarily middle-aged women are affected. In a literature review of 31 patients, the mean age was 67 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Spontaneous intramural hematoma of the esophagus usually presents initially with severe retrosternal or epigastric pain with or without radiation. The pain is described as abrupt in onset and is aggravated by swallowing.
• In one meta-analysis, 32% of patients presented with the triad of chest pain, hematemesis, and dysphagia; 99% of patients had at least one of these symptoms.

Physical

A complete and thorough physical examination should be performed.

• Asking a patient to take a sip of water as part of the general examination may help to unmask symptoms of dysphagia. This may help toward distinguishing between cardiac chest pain and an esophageal disorder causing chest pain.
• Palpation looking for the presence of crepitus (suggesting the presence of air under the skin) along the neck, back, and chest can help to rule in or out the presence of an esophageal perforation.

Causes

Esophageal hematomas typically occur in the setting of vomiting or retching, although spontaneous hematomas (more commonly in patients with bleeding disorders) may also occur.

• Precipitating or predisposing factors to esophageal hematoma include the following:
• • Coagulopathies, such as hemophilia, or treatment with anticoagulants or aspirin
  • Instrumentation, such as with endoscopy or variceal sclerotherapy
  • Foreign body ingestion
  • Chest trauma
  • Food-induced injury, as a result of abrasive trauma by foodstuffs
  • Cardioversion and subsequent anticoagulation
  • Toxin ingestion

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Dissection of the thoracic aorta
Aortoesophageal fistula

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The laboratory workup should include hemoglobin concentration and coagulation profile with platelet count.
• Cardiac enzymes and troponin levels should be drawn to exclude a cardiac cause for the patient's chest pain.

Imaging Studies

• Chest radiograph
• • Chest radiographs may reveal a broadened mediastinal mass or bilateral pleural effusions.
  • Preliminary study helps to exclude a perforation and other pathologies included in the differential diagnosis of chest pain.
• Barium swallow (esophagram)
• • Typically, this study helps to confirm the diagnosis, revealing a filling defect in the mid and lower esophagus, usually on the posterior wall, with luminal narrowing and sometimes with mucosal irregularity.
  • Extravasation into the mediastinum is not observed unless a perforation has occurred.
  • A double barrel sign or a mucosal stripe sign may be demonstrated, that is, double columns of contrast medium separated by a radiolucent stripe and a large intramural mass that reflects a mucosal dissection that allows extravasation of contrast material into the hematoma.
• CT scan with contrast
• • CT scan reveals a nonenhancing, eccentric, well-defined, intramural esophageal mass that has the density of blood.
  • CT scan can help to better characterize esophagram findings, accurately define the extent of intramural dissection, and exclude esophageal perforation.
  • CT scan is useful in excluding other conditions that may mimic esophageal hematoma, including mass lesions, aortic dissection, and pulmonary embolism.
• MRI
• • MRI can help demonstrate the extent of the hematoma in various planes and can help rule out additional mediastinal pathology.
  • MRI is indicated for patients who cannot have a CT scan because of an allergy to iodinated contrast medium or renal impairment.
• An endoscopic ultrasound (EUS) shows an intramural hypoechoic submucosal mass.

Procedures

• Upper endoscopy
• • It has been suggested that fiberoptic endoscopy is relatively contraindicated in the further evaluation of esophageal hematoma because many intramural hematomas are contained perforations that could be worsened by the insufflation of air.
  • Others endorse the use of endoscopy in the initial evaluation once esophageal perforation has been ruled out.
  • Endoscopically, an esophageal hematoma is described as a bluish or purplish colored, submucosal mass protruding into the esophageal lumen.
  • Endoscopy can precisely identify the tear in the mucosa, but the risk of the procedure should be weighed against the need for this information and the generally uncomplicated course that these patients follow.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

For spontaneous intramural hematoma, conservative therapy leads to an excellent prognosis. Esophageal hematomas generally resolve within 2-3 weeks with no long-term sequelae.

• Nothing by mouth (NPO) for the first several days. Oral intake should be reintroduced gradually. A soft diet may be started in a stable patient on days 4-6. Parenteral feeding is generally not required, as most patients are able to swallow within a few days.
• Provide intravenous fluids while the patient is NPO and transfusion of blood if needed.
• • Acid suppression should also be considered to reduce the risk of esophageal ulceration.
  • Antiemetics are indicated as needed.
• Correction of any coagulation abnormalities is indicated.
• Occasionally, extensive esophageal hematomas have been treated by sclerosant injections.
• • Because this entity is so rare, a clear indication for this therapeutic approach has not yet been established.
  • Complications during endoscopic sclerotherapy include rupture of the intramural hematoma.

Surgical Care

• Surgery is only indicated in patients with massive ongoing hematemesis. This occurred in 19% of patients, as reported in a literature review of 31 patients with esophageal hematoma.
• Via a right thoracotomy, an esophagotomy may expose the bleeding tissue, which is then oversewn.

Consultations

• Cardiologist
• Gastroenterologist
• Thoracic surgeon

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Acid suppression by histamine 2 (H2)-receptor antagonists or proton pump inhibitors is useful to treat or prevent esophageal ulcerations.

Drug Category: Proton pump inhibitors

Inhibit gastric acid secretion by inhibition of the H⁺/K⁺/ATP-ase enzyme system in the gastric parietal cells. These agents are used in cases of severe esophagitis and in patients not responding to H2-antagonist therapy.

Drug Category: H2-receptor antagonists

Reversible competitive blockers of histamine at the H2 receptors, particularly those in the gastric parietal cells where they inhibit acid secretion. The H2 antagonists are highly selective, do not affect the H1 receptors, and are not anticholinergic agents.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Follow-up care after the acute event has resolved with either a barium swallow or endoscopy is necessary to rule out any additional esophageal disease not seen on the initial evaluation. This can be done prior to discharge or can be arranged to be done on an outpatient basis.

Complications

• Full-thickness perforations of the esophageal wall have been reported during endoscopy of an esophageal hematoma.

Prognosis

• Long-term results are very good with conservative and supportive treatment.
• Intermittent odynophagia usually subsides within 2 weeks after the primary event.
• Recurrence is extremely rare.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Distinguishing esophageal hematoma from cardiac ischemia or pulmonary embolism is critical because esophageal hematoma can be worsened by thrombolysis and anticoagulation.
• In contrast to an intramural esophageal hematoma, an aortoesophageal fistula is a life-threatening condition that may present as a submucosal esophageal hematoma. On endoscopy, an aortoesophageal fistula is noted as a pulsatile esophageal mass. The prognosis is grave if surgical intervention is delayed.
• Filling defects on the esophagogram have been confused with tumors. Conversely, a follow-up endoscopy or barium swallow should be performed to ensure that a tumor or other esophageal pathology was not missed on the initial evaluation.
• Aortic dissection is a surgical emergency that must also be distinguished from esophageal hematoma in the initial evaluation.
• Monitor for the development of a fever or pleural effusions, which may indicate an esophageal perforation missed during the initial evaluation.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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• Tong M, Hung WK, Law S. Esophageal hematoma. Dis Esophagus. 2006;19(3):200-2.
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Article Last Updated: Jul 20, 2006