Intramural Esophageal Dissection: A Rare Complication of ERCP

Abstract

Intramural esophageal dissection (IED) is a rare condition characterized by a mucosal tear leading to an increase in intraesophageal pressure, which potentiates a full separation of the mucosa and/or the submucosa from the deeper muscular layers, resulting in the creation of a true and false lumen in the esophagus. Common causes of IED are iatrogenic; esophagogastroduodenoscopy (EGD), nasalgastric tube placement, transesophageal echocardiogram, variceal sclerotherapy, argon plasma coagulation (APC), dilations, and even biopsy. We present a case of IED in a patient undergoing endoscopic retrograde cholangiopancreatography (ERCP). A 72 year old Caucasian female with no significant past medical history presented with an intertrochanteric fracture from a mechanical fall. Incidentally, the patient was also found to be jaundiced, and her liver function tests were consistent with biliary obstruction. Computed tomography (CT) showed severe intrahepatic biliary dilatation with underlying mass at the porta hepatis, ERCP was recommended for further evaluation. The duodenoscope was unable to easily pass into the esophagus and faced resistance while advancing, prompting its removal. An adult endoscope was placed noting a submucosal tear in the proximal esophagus. A wire catheter was passed into the stomach; contrast was injected and did not reveal any extravasation. The endoscope was then removed and a nasal scope was placed over the wire, confirming a submucosal tear in the esophagus (Figure 1, 2) with no signs of a full thickness tear. An Isovue esophagram revealed a double barrel esophagus compatible with intramural dissection of the esophagus (Figure 3). A covered esophageal stent was later placed. She was able to resume a diet by mouth seven days later. IED is a rare condition with its most common cause being iatrogenic. We present a case of IED in an attempted ERCP. Based on literature review, there are no findings to date referencing IED as a complication of ERCP. Because the side-viewing scope used in ERCPs provides limited visualization of the esophagus, endoscopists should be cognizant of the risk of IED, especially when experiencing resistance in passing the scope. Furthermore, IED should be mentioned when reviewing possible complications of any upper endoscopic procedure.Figure: Endoscopic view of esophageal dissection depicting the true and false lumen.Figure: Endoscopic view of esophageal dissection at the GE junctionFigure: Fluoroscopic evaluation showing a double barrel esophagus.