1797 Intramural Esophageal Dissection: A Rare Cause of Hematemesis

Abstract

INTRODUCTION: Intramural esophageal dissection (IED) was first described by Williams in 1957. It is a rare form of acute esophageal trauma defined as an injury in the esophageal submucosal layer extending between the mucosa and muscular layer. Patients may present with acute chest pain, epigastric pain, dysphagia, retching or hematemesis. It most cases, IED is associated with trauma during food ingestion. CASE DESCRIPTION/METHODS: A 91-year-old Veteran presented to the Phoenix VA Health Care System’s Emergency Department ED with a 1-day history of retching followed by dysphagia after pill ingestion. He subsequently developed massive hematemesis described as a ‘basin full of bright red blood’ and lightheadedness. His medications were notable for aspirin 81 mg daily, but no anticoagulant. A computed tomography scan of the chest showed severely thickened esophageal wall without gas or fluid in the mediastinum. Urgent esophagogastroduodenoscopy (EGD) was performed revealing a blood clot in the oropharynx and around the Endotracheal tube, and a large organized hematoma without active bleeding in the mid to distal esophagus adherent to the esophageal wall. Multiple attempts to remove the blood clot were made by snare and endoscopic basket without success. A repeat follow-up EGD was performed demonstrating the same hematoma with successful removal via distal attachment cap. Beneath the hematoma, a 10-cm, non-circumferential, deep submucosal tear was seen from mid- to distal esophagus associated with small spots of bleeding (Figure 1). Nine endoscopic clips were placed (Resolution clip, Boston Scientific) (Figure 2). The patient did not develop any further hematemesis, and his dysphagia improved throughout admission. DISCUSSION: We present a case of spontaneous IED involving 10cm of the esophagus in a 91-year-old Veteran treated with endoscopic zipper clipping to achieve successful hemostasis. While conservative management is reported in most cases in the form of bowel rest, this case demonstrates the significance of endoscopic evaluation when hemodynamic instability is present. For this Veteran, the hematoma provided a natural form of hemostasis until endoscopic clips could be placed to stop bleeding.