Spontaneous Intramural Hematoma of the Esophagus: An Unusual Case of Dysphagia and Mediastinal Mass

Abstract

Introduction: Intramural esophageal hematoma (IEH) is an uncommon but potentially lethal cause of chest pain with accompanying dysphagia. While the majority of cases can be treated with conservative management, we present a case of a spontaneous IEH that later progressed to a symptomatic fibrotic, scared hematoma requiring surgical intervention. Case Report: A 41-year-old female presented to the ED with two days of progressively worsening, severe, non-radiating abdominal pain. She has associated nausea and non-bloody emesis. She denies having heartburn, dysphagia, distention or a change in her bowel habits. Labs show a mild leukocytosis of 10.7; otherwise chemistries, LFTs and lipase are all within normal limits. A KUB shows possible ileus and RUQ ultrasound was normal. CT shows a large mass in the posterior mediastinum with areas of high attenuation, measuring 11.4 x 7.8 x 5.6 in maximal cross sectional diameter (Fig. 1). It extends through the esophageal hiatus with a mass effect on the GE junction, proximal stomach and left atrium. EUS demonstrated an esophageal intramural mass in the wall of the esophagus with associated pericardial effusion. Fine needle aspiration of the mass was significant for gross blood along with inflammatory cells and abundant fibrotic debris (Fig. 2-3). At this time thoracic surgery was consulted to evaluate for potential surgical management of the mass. The patient underwent a left thoracotomy with exploration of the mediastinum where they found a fibrosed hematoma, which was excised. The patient remained in the hospital and was discharged several days later with resolution of symptoms.Figure: CT Chest showing dilated distal esophagus with Intramural Nodule.Figure: EGD showing intramural hematoma.Figure: EUS demonstrating intramural lesion found in the lower third of esophagus appearing to originate from within muscularis propia.Discussion: Intramural esophageal hematoma (IEH) is a rare cause of progressive, chest pain. The majority of cases are due to the use of anticoagulation, trauma, foreign body ingestion, or complications of instrumentation6. While the majority of cases resolve spontaneously, there is scarce literature dictating the management of persistent fibrotic hematomas. Surgical options include both open thoracotomy and video-assisted thorascopic surgery. We present this case in hopes to increase the breadth of knowledge regarding complicated IEH and demonstrate the room for future therapeutic endoscopic interventions opposed to invasive surgery. Finally, we hope to portray a case of a non-resolving IEH to elude on the potential benefit of early reimaging in patients with persistent symptoms.