1789 Pseudotumor Esophagus: Acute Dysphagia Secondary to Mallory-Weiss Tear Associated Blood Clots

Abstract

INTRODUCTION: Acute onset dysphagia secondary to the mass effect from blood clots related to Mallory-Weiss tears (MWT) has not been reported in the literature. We present two such cases, both of which initially were thought to have a neoplastic etiology. CASE DESCRIPTION/METHODS: Case 1: A healthy 60-year-old woman developed acute dysphagia following impaction of a piece of steak. She forcefully regurgitated it with a coat of blood but continued to have substernal chest pressure and dysphagia with sticking at her suprasternal notch. A chest x-ray raised concern for pneumomediastinum, prompting an esophagram that showed a distal esophageal filling defect suggestive of obstructive neoplasm (Figure 1A). An upper endoscopy showed a long mucosal tear in the distal esophagus with a large adherent blood clot at the apex that could not be dislodged. The patient remained nil per os over the next couple of days with improvement in her discomfort. A repeat esophagram showed no filling defects (Figure 1B). Upon resumption of her diet, she experienced no further dysphagia. Case 2: An 80-year-old man with severe ischemic cardiomyopathy presented with volume overload. He was started on a heparin drip after an atrial thrombus was found on echocardiogram. One day later, he had sudden onset projectile vomiting and subsequent dysphagia with substernal sticking. An upper endoscopy showed a 3 cm fixed, partially obstructive mass-like lesion in the lower third of the esophagus with oozing at the base (Figure 2A). Biopsies showed non-specific findings including necrosis and foreign material. The following day, the patient tolerated solid food without dysphagia. A second upper endoscopy showed a 3 cm esophageal tear with a small adherent clot at the site of the previously noted mass-like lesion (Figure 2B). He continued to tolerate a regular diet without further symptoms. DISCUSSION: The presentation of MWT associated blood clots causing dysphagia and resembling distal esophageal neoplasms is novel. Both our cases experienced forceful regurgitation or emesis prior to the onset of dysphagia, suggesting a mucosal tear as the instigator with subsequent development of a large clot in the esophageal lumen. In each instance, resolution of symptoms correlated temporally with clearance of the clot. MWT are most likely to present with hematemesis but in rare cases may form a large blood clot mimicking a neoplastic process with resultant dysphagia. Awareness of such presentations may prevent unnecessary workups.