Esophageal Hematoma

Introduction

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

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