Esophageal Apoplexy

Abstract

Purpose: An 83 year old healthy female presented with one episode of hematemesis. She denied prior episodes of hematemesis, abdominal pain and melena. She c/o acute onset solid food dysphagia but denied odynophagia, recent trauma and retching. She was on no medications, did not smoke or drink etoh and had no family history of GI malignancies. An EGD revealed a large mass in the proximal esophagus that was thought to be composed of blood vessels. The endoscopists were concerned for the presence of esophageal varices, but were unsure and transferred her to our tertiary care center. We repeated the upper endoscopy on her arrival; at 20 cm within the proximal esophagus we encountered a large submucousal mass that extended continuously to 40 cm. The lesion was on the posterior wall of the esophagus, was 2 cm wide and 20 cm long. It appeared beefy red in color with multiple areas of purple discoloration and ulceration. CT scan of the thorax revealed a large submucousal mass within the esophagus which was concerning for malignancy, however a definitve diagnosis could not be made. Conservative management was undertaken with plans for repeat endoscopy as we entertained a diagnosis of esophageal apoplexy. Repeat endoscopy was performed two weeks later with near resolution of the findings thus confirming our suspicion. Esophageal apoplexy, also known as esophageal intramural hematoma is a rare cause of hematemesis. Patients usually present with retrosternal chest pain, dysphagia and hematemesis. Frequently the patient is an older female on anticoagulants. Precipitating events include food bolus impactions, vomiting with recurrent retching, recent esophageal instrumentation including dilation and biopsy. Occasionally esophageal apoplexy occurs with no identifiable trigger. EGD helps with diagnosis and is especially useful to rule out esophageal cancer. Barium esophagram may show the “double barrel sign” suggesting intramural dissection. EUS and CT are useful to help confirm the diagnosis. Management is generally conservative as the hematoma usually resolves in 1–3 weeks. Prompt recognition is critical as the prognosis is excellent and the need for more invasive investigation and surgery is unnecessary.Figure: esophageal apoplexy.