3104 Esophageal Hematoma: A Colossal Obstacle

Abstract

INTRODUCTION: Esophageal hematomas are rare but well described phenomena that can present as retrosternal chest pain, hematemesis, and dysphagia. They are seen in association with anticoagulation therapy, mechanical trauma, and increased intraesophageal pressure as caused by excessive retching and vomiting. We describe a case of esophageal hematoma following catheter ablation for treatment of atrial fibrillation. CASE DESCRIPTION/METHODS: A 73 year old female with chronic obstructive pulmonary disease, nephrectomy, rheumatic heart disease status post mechanical mitral valve on warfarin, refractory atrial fibrillation was admitted for hematemesis after elective atrial fibrillation ablation. The patient underwent TEE during which an esophageal probe was required for repositioning of the esophagus. No blood was seen when the probe was removed, but at the end of the procedure the patient had hematemesis. INR at presentation was 3.7. The patient was emergently intubated and an EGD revealed a large clot occluding the mid-esophagus, denuded mucosa with oozing from multiple sites, and a large clot in the fundus (Figure 1). A chest CTA showed circumferential esophageal thickening and distention with non-enhancing blood products extending from above the thoracic inlet to the GE junction, with clot also outlined by oral contrast within the gastric lumen. No definite communication between the esophagus and atrial pulmonary veins was identified. A repeat endoscopy the next day again showed the large esophageal hematoma (Figure 2) and was aborted to avoid additional esophageal trauma. A week later, CTA chest showed persistent esophageal intramural hematoma with no evidence of aortoenteric fistula. Cardiothoracic surgery was consulted and placed a percutaneous gastrostomy tube. The patient was recovering well, but shortly upon extubation, the patient died of cardiorespiratory arrest. DISCUSSION: Esophageal hematomas typically develop in middle-aged women and present as a triad of retrosternal chest pain, dysphagia and hematemesis. The mechanism producing the hematoma may determine the site. For example, a hematoma from vomiting would be at the esophagogastric junction, whereas from a caustic substance might be at points of narrowing. It can be visualised on endoscopy or as a filling defect on barium esophagogram. Computed tomographic images reveal a mass confined to the esophageal lumen that does not enhance with injection of contrast medium. Conservative and supportive care remains the main therapeutic modality.