Intramural Esophageal Dissection Research Articles

Интрамуральная диссекция пищевода – редкое осложнение эозинофильного эзофагита

Eosinophilic esophagitis (EoE) is characterized clinically by typical endoscopic features and the presence of more than 15 eosinophils visible per high-power field in esophageal mucosal biopsy samples. Due to deep chronic eosinophilic inflammation, it can lead to complications, such as esophageal stenosis and rarely perforation. Intramural esophageal dissection (IED) is a previously undescribed complication of EoE in children. This article presents a clinical case of IED in a 15-year-old boy with clinical debut as sudden epigastric pain and nausea against the background of acute respiratory viral infection. Endoscopy, computed tomography, and X-ray examination revealed a double-barrel esophagus with two cavities, the esophagus itself and a blind diverticulum (pouch or “pocket”), in which granulation tissue and active inflammation with many neutrophils were detected. Initial histological assessment showed no significant eosinophilic infiltration in the esophagus. After 6 months, endoscopy revealed characteristic signs of EoE: longitudinal grooves and erosions, transverse rings, narrowing of the esophageal lumen. In the middle third, the picture of double-barrel esophagus remained unchanged, but without signs of acute detachment and with a dense septum between two esophageal cavities. Histologically, the infiltrate contained more than 50 eosinophils per high-power field. The diagnosis of EoE complicated by IED was established. A strict hypoallergenic diet and an oral gel budesonide were prescribed. Endoscopic dissection of the esophageal septum was performed, its patency was restored. In 2 months, during a re-examination after a course of pharmacotherapy and diet, there were no complaints, radiological evaluation of esophageal patency showed no abnormalities. Endoscopically, the esophagus was freely passable, there was a small fold at the surgical site, longitudinal grooves and small erosions in the lower third maintained. Histologically, the number of eosinophils decreased significantly. The therapy was continued. This clinical case demonstrates the possibility of IED development as a complication of EoE. The course of EoE can be asymptomatic, while IED can serve as the first manifestation of the disease. The endoscopic presentation of double-barrel esophagus is a consequence of dissection. The combination of a hypoallergenic diet, topical steroids, and endoscopic septectomy is effective in the treatment of EoE with IED. Key words: eosinophilic esophagitis, intramural esophageal dissection, double-barrel esophagus

An Unusual Case of Chest Pain and Pyrexia

Question: A 44-year-old man with tearing retrosternal pain for 2 weeks was admitted to our department. A day before the onset of symptoms, he had pharyngalgia, cough, sputum production, moderate pyrexia, and fatigue, which he thought was due to a common cold. He then had sudden-onset severe chest pain, which lasted 4 to 6 seconds and occurred every 30 seconds, with acid reflux and heartburn. The patient had consumed nothing after the start of the symptoms until this consultation. He denied emesis, hematemesis, melena, dysphagia, odynophagia, history of esophageal disease, eating hurriedly, ingestion of hot or rough food, anticoagulants, or foreign body. His medical history was significant for alcohol consumption (100 g/d) for more than 20 years. He visited a local hospital and underwent chest computer tomography (CT); however, the diagnosis was unclear, and an attempt to insert a nasogastric tube failed. The patient visited another hospital, and a CT scan revealed dilation of the esophageal lumen and thickening of the esophageal wall, with exudation in the periesophageal areas and lung fields. Esophagoscopy revealed a large depressed lesion at 20 cm from the incisors, measuring 1 cm in diameter and covered with pus. The background esophageal mucosa was severely inflamed and edematous. Contrast esophagography performed a week later showed accumulation of contrast medium in the middle and lower esophagus, which formed a sac-like shadow beside the esophagus, without communication with the thoracic or gastric cavity. The patient was treated conservatively, and his symptoms were partially relieved. Because the pathogenesis was still unknown, the patient was referred to our institution for further evaluation. What is the correct diagnosis and management of this condition? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult According to his medical history from other hospitals, normal electrocardiography and cardiac enzyme levels excluded the diagnosis of myocardial infarction; absence of hypertension and no abnormalities in aortic anatomy disclosed by means of contrast CT argued against aortic dissection; absence of emesis and no extravasation of contrast medium demonstrated by contrast esophagography excluded Boerhaave’s syndrome. Then contrast chest CT scan, which revealed thickening and liquid accumulation in the middle and lower esophageal wall, with little extra-esophageal air leakage and pneumonia (Figures A and B), and upper endoscopy (Figures C and D) were performed. A diagnosis of spontaneous intramural esophageal dissection (SIED) complicated by infectious esophagitis and pneumonia was made. SIED is a rare disease entity characterized by transverse and longitudinal separation of the mucosal and submucosal layers from the esophageal wall. Sudden onset of severe retrosternal chest pain, odynophagia, dysphagia, and hematemesis are the most common symptoms. Contrast esophagography and chest CT are the preferred methods to establish the diagnosis, and endoscopy also proved to be safe and useful in this condition. In most cases, conservative treatment has a good prognosis. Endoscopic interventions and surgery are alternative therapies when patients are refractory to conservative management or when complex complications occur.1Khil E.K. Lee H. Her K. Spontaneous intramural full-length dissection of esophagus treated with surgical intervention: multidetector CT diagnosis with multiplanar reformations and virtual endoscopic display.Korean J Radiol. 2014; 15: 173-177Crossref PubMed Scopus (4) Google Scholar,2Jung K.W. Lee O.J. Extensive spontaneous submucosal dissection of the esophagus: long-term sequential endoscopic observation and treatment.Gastrointest Endosc. 2002; 55: 262-265Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The patient was treated conservatively and discharged on day 35. Seven weeks later, follow-up endoscopy showed complete mucosal healing (Figure E), and he was asymptomatic at the time of writing (August 1, 2022).

Intramural esophageal dissection with eosinophilic esophagitis

Intramural esophageal dissection (IED), like esophageal perforation, is a rare complication of eosinophilic esophagitis (EoE). A 44-year-old woman who had experienced EoE for 8 years complained of food impaction, severe neck pain, and odynophagia as well as consulted the emergency unit. She was diagnosed with IED with mediastinal emphysema by enhanced computed tomography. After admission, she was treated conservatively with noninvasive treatment, including fasting, intravenous feeding, and antibiotics. Only nine cases of IED with EoE have been previously reported. All were male, and our patient was the first female patient from Asia. Urgent endoscopy was conducted in eight cases, of which three were worse after endoscopy, and in one case, total esophagectomy was conducted due to subsequent esophageal perforation. We did not perform urgent endoscopy on our patient because of a potentially increased risk of esophageal perforation through the procedure. When patients with EoE complain of severe retrosternal pain, odynophagia, or dysphagia, IED should be considered in addition to food impaction.

Esophagitis dissecans superficialis associated with acute transoral paraquat poisoning: Clinical study of 15 cases.

To analyze the clinical characteristics and therapeutic effects of transoral paraquat poisoning combined with Esophagitis dissecans superficialis (EDS). A retrospective observational study was conducted on paraquat poisoning patients between January 1, 2011 and August 30, 2016 in Qilu hospital. Fifteen patients with EDS were enrolled in this study. The clinical characteristics, prognosis, and pathological features of esophageal necrosis mucosa of these patients were retrospectively analyzed and summarized. Esophageal mucosal dissection occurs mainly within 3-8 days after transoral paraquat poisoning in 15 patients. Dosage of paraquat is range from 50 to 100 ml. Most patients have physical problems with swallowing before the intramural esophageal dissection occurred. And there are other symptoms, including sore throat or dysphagia (100%), nausea and vomiting (86.7%), heartburn or upper abdominal pain (73.3%), hematemesis (60%), abdominal distension (20%) and cough frequently (6.7%). In death group, most patients demonstrate features of the multiple organ failure when the esophageal mucosal stripping happened, including lung injury, renal failure, and hepatic failure. The shape of esophageal dissection was tubular in 60%, irregular in 40%, and they vary in size. Pathological examination showed extensive injury, necrosis and hemorrhage of digestive tract epithelium, and obvious inflammatory reaction of epithelial tissue. Transoral paraquat poisoning has certain damage to the patient's esophageal mucosa, and some may be complicated with EDS, and the prognosis is poor, especially when combined with multiple organ dysfunction. Esophageal damage is mainly located in the esophageal mucosa and have different degrees. Special attention should be paid on such patients.

S1905 An Accidental POEM

INTRODUCTION: Intramural esophageal dissection (IED) is an uncommon condition that typically arises as a complication of instrumentation, foreign body ingestion, or food bolus impaction. It also can occur spontaneously in older patients on anticoagulation. Transesophageal echocardiography (TEE) involves blind placement of an ultrasound probe in the esophagus and can be associated with esophageal dissection. We describe a patient who developed iatrogenic IED from TEE after a recent food bolus impaction. CASE DESCRIPTION/METHODS: A 69-year-old female with gastroesophageal reflux disease, recurrent dysphagia, and coronary artery disease (CAD) was transferred for coronary artery bypass graft (CABG) evaluation due to a non-ST segment elevation myocardial infarction. This occurred one day after an esophagogastroduodenoscopy (EGD) at an outside hospital for food bolus impaction. EGD was notable for the food bolus impacted at the upper esophageal sphincter (UES), concern for occult UES stricture, and grade D esophagitis. The patient underwent urgent CABG along with intraoperative TEE due to the severity of multivessel CAD. Postoperatively she reported dysphagia to pills and some liquids, concerning for esophageal injury from TEE. Esophagram showed a linear lucency dividing the esophageal tract into 2 lumens without transmural contrast extravasation (Image 1). The lumen on the right was 12.6 centimeters with a blind ending. The patient was diagnosed with iatrogenic IED from TEE. She was treated conservatively with nil per os, proton pump inhibitor, and empiric piperacillin and tazobactam. Serial esophagography on days 3 and 7 from diagnosis showed improvement (Image 2) (Image 3). Her diet was advanced, and she was discharged on soft diet with outpatient follow up. DISCUSSION: IED occurs due to traumatic breaks in the mucosa that expand when intraesophageal pressure increases. Our patient’s risk factors for IED include recent food bolus impaction, possible UES stricture, recent endoscopic procedure, and prolonged intraoperative TEE. Our patient’s IED likely was provoked by a break in the mucosa from food bolus impaction exacerbated by instrumentation and increased intraesophageal pressure during TEE. Gastroenterologists should include IED as a differential diagnosis in patients with appropriate risk factors who have odynophagia and/or dysphagia following TEE. Management of IED without perforation is conservative.Image 1.: 12.6 cm right false esophageal lumen with blind ending.Image 2.: Interval improvement of esophageal dissection with partial closure of false lumen.Image 3.: Near complete closure of false esophageal lumen.

COMPLICATIONS OF EOSINOPHILIC ESOPHAGITIS

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Idiopathic eosinophilic esophagitis is a chronic immune mediated eosinophilic infiltration of the esophageal mucosa. Clinical presentation is in the form of dysphagia and esophageal food impaction (1). Esophageal dissection is a complication which can occur spontaneously or secondary to a clinical complication of food impaction, Boerhaave syndrome or diagnostic and therapeutic interventions. Case reports have highlighted esophageal dissection including spontaneous dissection (2). Association between chronic inflammatory conditions and thromboembolism is well known, however there is only one case report of venous thromboembolism (VTE) occurring in eosinophilic esophagitis (3). CASE PRESENTATION: A 40-year-old male with no known past medical history presented to our emergency department with complaints of continuous chest pain, persistent emesis (occasionally blood tinged), dysphagia and odynophagia after eating ribs at a barbeque one day prior. The patient had no reported history of allergies, atopy, rhinitis, or asthma. Laboratory evaluation revealed leukocytosis of 11.0 k/uL with an eosinophil percentage of 1.8%. CT chest revealed food impaction in the esophagus with an incidental finding of right upper lobe acute pulmonary emboli (PE). The patient was admitted to the MICU for emergent endoscopy which revealed a large mucosal tear and food bolus impaction in the distal esophagus. Cold biopsies were taken. Patient was started on a heparin drip in MICU. Persistent chest pain led to an esophageal barium study which showed a double barrel sign suggestive of intramural esophageal dissection. Cardiothoracic surgery was consulted, patient was kept NPO for 72 hours and treated with a proton pump inhibitor for spontaneous resolution of esophageal dissection. Repeat esophageal barium study confirmed resolution and patient was restarted on enteral nutrition. The patient was discharged after being able to tolerate a soft diet and switched to an oral anticoagulation agent. Following up in two weeks, the patient remained asymptomatic and biopsy confirmed eosinophilic esophagitis. DISCUSSION: To our knowledge, this is the first reported case in which a patient presented with all of the above categories of complications, both local (food impaction and esophageal dissection) and systemic (VTE). This unique clinical presentation made the medical management increasingly challenging. In our case the patient was started on a heparin drip in the MICU for continuous monitoring in case the need for emergent repeat endoscopy or surgical intervention arose. Though conservative management with proton pump inhibitors and nil per mouth is the mainstay of management, surgery must be considered if esophageal perforation or mediastinal abscess occur. CONCLUSIONS: Surgery must be considered if esophageal perforation or mediastinal abscess occur. Reference #1: 1. Desai TK1, Stecevic V, Chang CH, Goldstein NS, Badizadegan K, Furuta GT. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest Endosc. 2005 Jun;61(7):795-801. Reference #2: 2. Straumann A1, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol. 2008 May;6(5):598-600. doi: 10.1016/j.cgh.2008.02.003. Epub 2008 Apr 14 Reference #3: 3. Patricia D. Jonesa, b Stephan Mollc Evan S. Dellona, b. Pulmonary Embolism in a Patient with Eosinophilic Esophagitis: Causal or Coincidental? Case Rep Gastroenterol 2013;7:82–88 DISCLOSURES: No relevant relationships by Michael Hoffman, source=Web Response No relevant relationships by Benjamin Mba, source=Web Response No relevant relationships by Heba Naseem, source=Web Response No relevant relationships by Rabab Nasim, source=Web Response No relevant relationships by Marcus Stammen, source=Web Response

Circumferential intramural esophageal dissection with large mucosal defect.

Intramural esophageal dissection (IED) is an uncommon entity characterized by mucosal rupture creating a false lumen. It usually develops following endoscopy or in old patients with bleeding tendencies and spontaneous presentation possesses diagnostic dilemma. Managing partial IED is simpler than circumferential IED. Due to rarity of presentation, management is not standardized. We report circumferential IED in a young patient and challenges faced during diagnosis and management.

Intramural Esophageal Dissection After Cardiopulmonary Resuscitation

A 42-year-old woman with coronary artery disease on dual-antiplatelet therapy and end-stage renal disease presented with hematemesis, new thrombocytopenia, and 4-g drop in hemoglobin. She was hemodynamically stable and described chest pain leading up to the admission. One month prior she suffered a cardiac arrest necessitating cardiopulmonary resuscitation with compressions. Esophagogastroduodenoscopy demonstrated a large blood clot in the proximal esophagus, with sloughing mucosa underneath (Figure A) suspicious for a semicircumferential intramural esophageal dissection.

Intramural esophageal dissection after endoscopy: a case report in a hypopharyngeal cancer patient treated with concurrent chemoradiotherapy

Intramural esophageal dissection after endoscopy: a case report in a hypopharyngeal cancer patient treated with concurrent chemoradiotherapy

Endoscopic Transection for Intramural Esophageal Dissection Caused by a Retropharyngeal Abscess

Endoscopic Transection for Intramural Esophageal Dissection Caused by a Retropharyngeal Abscess

ESOPHAGEAL INTRAMURAL DISSECTION WITH PNEUMOMEDIASTINUM SECONDARY TO FOREIGN BODY INGESTION

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Esophageal injuries are associated with significant morbidity and mortality. Intramural esophageal dissection (IED) is a rare entity involving separation of the mucosal and muscular layers of the esophagus creating a true and false lumen (1). We present a patient with esophageal dissection secondary to foreign body ingestion. CASE PRESENTATION: A 38-year-old freedom impaired man with schizophrenia presented with severe odynophagia after a suicide attempt by ingestion of plastic bags and a spoon. He vomited multiple times afterwards and was intubated due to respiratory distress. He was afebrile and hemodynamically stable. Physical exam was significant for crepitus around the neck and shoulders with severe pain to palpation. Abnormal labs included mild leukocytosis and elevated BUN, Cr, and CK. The esophagram revealed subcutaneous and mediastinal emphysema with no extravasation of contrast. Cervical and thoracic computed tomography (CT) with barium revealed neck and upper chest soft tissue emphysema involving the retropharyngeal space along with pneumomediastinum and pneumopericardium (Figure 1 & 2). ENT performed a microdirect laryngoscopy and rigid bronchoscopy removing a foreign body from the left hypopharynx. Given the risk for mediastinitis, intravenous antibiotics were started. Two days later, ENT repeated direct laryngoscopy and found an esophageal dissection extending from the level of C2 to T2 with separation of the posterior pharyngeal wall from the deep vertebral space (Figure 3). The patient was kept intubated to allow time for healing along with moderate sedation to prevent coughing from disrupting the epithelialization. Repeat CT of the head and neck showed minimal emphysema, esophageal and prevertebral soft tissue thickening, pleural effusions, and pneumonia. The patient was successfully extubated. Repeat esophagram noted contrast in the right and left mainstem bronchi. Given aspiration risk, an open gastrostomy tube was placed for enteral nutrition. DISCUSSION: IED is commonly due to iatrogenic interventions, but can occur rarely secondary to foreign body ingestion. Other causes include a sudden increase in intra-esophageal pressure or submucosal bleeding (1). Diagnosis is confirmed by esophagram, CT scan or standard endoscopy. IED may present with pneumomediastinum, which is hypothesized to be secondary to gas diffusion across the esophageal muscular layers (2). Management is typically conservative. CONCLUSIONS: Foreign bodies are a rare cause of IED. Early investigation and maintaining a strong suspicion for esophageal perforation are key to ensuring a favorable outcome. Reference #1: Soulellis CA, Hilzenrat N, Levental M. Intramucosal esophageal dissection leading to esophageal perforation: case report and review of the literature. Gastroenterol Hepatol (NY). 2008;4(5):362-365. http://www.ncbi.nlm.nih.gov/pubmed/21904510. Reference #2: Lee CH, Chen WP, Feng YM, Huang PY. Iatrogenic Full-Length Intramural Esophageal Dissection Associated with Pneumomediastinum after Attempted Diagnostic Gastroscopy. Journal of Clinical Case Reports. 2014; 4:443. DISCLOSURES: No relevant relationships by naseem helo, source=Web Response My spouse/partner as a Speaker/Speaker's relationship with Salix Please note: $1001 - $5000 Added 03/13/2019 by Ebtesam Islam, source=Web Response, value=Speaker fee No relevant relationships by Sarah Jaroudi, source=Web Response No relevant relationships by Barbara Mantilla, source=Web Response No relevant relationships by Kenneth Nugent, source=Web Response

1797 Intramural Esophageal Dissection: A Rare Cause of Hematemesis

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.

1771 Eosinophilic Esophagitis Presenting With Esophageal Wall Dissection

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated, inflammatory disease with a wide spectrum of presentation from mild dysphagia to food impaction. We describe the presentation and management of a patient whose initial presentation of EoE included the rare complication of esophageal dissection. CASE DESCRIPTION/METHODS: A 30-year old Caucasian male presented to the emergency department after 10 days of dysphagia and odynophagia. His physical exam was normal. Initial laboratory evaluation revealed mildly elevated troponin I and leukocytosis. CT imaging with IV contrast showed an air-fluid level within the distal esophagus. EGD could only be completed with a pediatric gastroscope (5.4-mm) due to severe, diffuse narrowing of the esophagus. The entire esophagus had findings of EoE including edema, furrowing, and circumferential rings. The lumen of the proximal esophagus was 12-15 mm with acute narrowing to 7mm at 27-cm. Most notable was a 1-cm x 2-cm hole at 25-cm which communicated with a fluid-filled, granulation tissue lined space that paralleled the distal esophagus (Figure 1). Biopsies showed >50 Eos/hpf consistent with EoE. The patient was started on broad-spectrum antibiotics, IV proton pump inhibitor therapy, topical steroid and kept NPO. CT imaging with IV and gastrograffin contrast demonstrated a long segment intramural dissection with a double-barreled esophageal lumen (Figure 2). Following consultation with cardiothoracic surgery, endoscopic management was pursued. Endoscopic suturing was not attempted given severe luminal narrowing. The tissue proved too fibrotic for hemostasis clips. A through-the-scope, fully-covered self-expanding esophageal stent (FCSEMS) was deployed across the defect and a feeding tube was inserted. An elemental diet was started. Follow-up imaging showed obliteration of the false lumen by post-procedure day 9 (Figure 3). Repeat EGD one month later showed an intact lumen but with delicate-appearing granulation tissue at the location of the previous hole (Figure 4), thus another FCSEMS was placed and elemental diet was resumed with plans for repeat EGD in 4 weeks. DISCUSSION: Intramural esophageal dissection is a rare, potentially life-threatening complication of EoE which can be medically and endoscopically managed. “The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the United States Air Force, the Department of the Navy, Department of Defense, or the U.S. Government.”

Tips and tricks for avoiding the dreaded intramural esophageal dissection during peroral endoscopic myotomy: recognize!

Tips and tricks for avoiding the dreaded intramural esophageal dissection during peroral endoscopic myotomy: recognize!

Intramural Esophageal Dissection: A Rare Cause of Acute Chest Pain after Percutaneous Coronary Intervention

Intramural esophageal dissection is a condition that typically presents with chest pains and may be associated with hematemesis, odynophagia, and hematemesis. The role of antiplatelet/anticoagulant agents in the development of intramural esophageal hematoma is controversial. The management of intramural esophageal dissection is generally conservative with low mortality and morbidity. The case described here is a 66-year-old woman who presented with chest pains, odynophagia, and dysphagia 1 month after percutaneous coronary intervention while taking ASA (80 mg daily) and clopidogrel (75 mg daily) for dual antiplatelet therapy. The patient was diagnosed as intramural esophageal dissection and underwent successful conservative medical management. The relative contribution of dual antiplatelet therapy with ASA and clopidogrel after percutaneous coronary intervention in this case is, albeit uncertain, a possibility.

Spontaneous intramural esophageal dissection preceded by intramural esophageal hematoma: Report of a case study

Spontaneous intramural esophageal dissection (IED) is a rare disorder characterized by acute symptoms, including chest pain, odynophagia, dysphagia, or hematemesis and remarkable endoscopic or radiographic findings. The pathophysiology is complex and remains poorly understood. Here, we report a 63‐year‐old woman who presented with progressive odynophagia, dysphagia, and weight loss. We diagnosed spontaneous IED with false lumen formation extending to the stomach using ultra‐thin upper endoscopy and water‐soluble contrast esophagogram. Comparing the patient's chronological computed tomographic images before and after symptom onset, we found that spontaneous IED was preceded by an intramural esophageal hematoma. Her symptoms persisted after 3 weeks of conservative treatment. Therefore, combined modalities of endoscopic transection and tissue glue application were given, and her symptoms improved gradually.

Intramural esophageal dissection: a case report and imaging diagnosis analysis

Intramural esophageal dissection: a case report and imaging diagnosis analysis

Solving the Maze: Restoring the Oesophageal Lumen After Defective Mucosal Healing of a Stented Circumferential Intramural Esophageal Dissection

Solving the Maze: Restoring the Oesophageal Lumen After Defective Mucosal Healing of a Stented Circumferential Intramural Esophageal Dissection

Surgical versus conservative management for suppurative intramural esophageal dissection

Often presented with an insidious onset, intramural esophageal dissection (IED) is a rare disease which has been mostly treated conservatively, though the treatment for infectious cases is still controversial. Two cases are reported here as follows: one was approached surgically by thoracoscopic mediastinotomy and neck debridement and the other was treated conservatively. The latter subsequently developed septic shock and was readmitted with intensive care. Both patients eventually recovered and resumed oral intake without requiring esophagectomy. Comparing these two cases of IED, one with a mucosal perforation and the other without, surgical intervention revealed the advantages of definitive isolation of pathogen and rapid mechanical removal of pus. Surgical risks should be evaluated against the severity, such as the presence of a mucosal perforation and the risk of a protracted clinical course for IED.

Intramural Esophageal Dissection: A Rare Complication of ERCP

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.