Korean J Gastroenterol.  2012 Oct;60(4):249-252. 10.4166/kjg.2012.60.4.249.

A Case of Conservatively Resolved Intramural Esophageal Dissection Combined with Pneumomediastinum

• Cha IH
• Kim JN
• Kwon SO
• Kim SY
• Oh MK
• Ryu SH
• Kim YS
• Moon JS

• KMID: 1775809
• DOI: http://doi.org/10.4166/kjg.2012.60.4.249

Abstract

Intramural esophageal dissection (IED) is a rare form of esophageal injury. We report a rare case of spontaneous IED complicated with pneumomediastinum and successfully improved by conservative management. A 46-year-old man presented to the emergency department with chest pain and hematemesis. The endoscopic diagnosis was suspicious of IED. Chest CT scan performed to rule out complication noted IED combined with pneumomediastinum. He was managed conservatively with nil per oral, intravenous antibiotics and parenteral nutrition. Follow up study after 2 weeks later showed near complete resolution of IED. IED should be included in the differential diagnosis for unexplained acute chest pain, especially, associated with dysphagia and hematemesis. IED with pneumomediastinum or mediastinitis require prompt surgery. So far, there is no case report of IED combined with pneumomediastinum which resolved without surgical treatment. In this case, IED combined with pneumomediastinum has improved by conservative management, so we present a case report.

Keyword

Intramural esophageal dissection; Mediastinal emphysema; Conservative management

MeSH Terms

Anti-Bacterial Agents/therapeutic use
Esophageal Diseases/complications/*diagnosis/drug therapy
Gastroscopy
Hematemesis/complications/diagnosis
Humans
Male
Mediastinal Emphysema/complications/*diagnosis/drug therapy
Middle Aged
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Endoscopic finding of the esophagus on admission. One ovoid discrete esophageal ulcer was noted at 24 cm from the incisor.

• 

  Fig. 2 Chest CT scans in the axial (A) and coronal (B) planes on admission. Esophageal wall thickening with a eccentric intramural mass and free air (asterisk) were noted within the mediastinum.

• 

  Fig. 3 Chest CT scans in the axial (A) and coronal (B) planes on 2 weeks later. Near complete resolution of the esophageal wall thickening and the pneumomediastinum were noted.

• 

  Fig. 4 Endoscopic finding of the esophagus on 6 weeks later. Near complete resolution of the esophageal ulcer was noted.

Reference

1. Restrepo CS, Lemos DF, Ocazionez D, Moncada R, Gimenez CR. Intramural hematoma of the esophagus: a pictorial essay. Emerg Radiol. 2008. 15:13–22.

2. Beumer JD, Devitt PG, Thompson SK. Intramural oesophageal dissection. ANZ J Surg. 2010. 80:91–95.

3. Hiller N, Zagal I, Hadas-Halpern I. Spontaneous intramural hematoma of the esophagus. Am J Gastroenterol. 1999. 94:2282–2284.

4. Steadman C, Kerlin P, Crimmins F, et al. Spontaneous intramural rupture of the oesophagus. Gut. 1990. 31:845–849.

5. Adachi T, Togashi H, Watanabe H, et al. Endoscopic incision for esophageal intramural hematoma after injection sclerotherapy: case report. Gastrointest Endosc. 2003. 58:466–468.

6. Heceta WG, Wruble LD, Pate JW. Esophageal obstruction due to intermuscular hematoma following pneumatic dilatation. Chest. 1976. 69:115–117.

7. Lauzon SC, Heitmiller RF. Transient esophageal obstruction in a young man: an intramural esophageal hematoma? Dis Esophagus. 2005. 18:127–129.

8. Piccione PR, Winkler WP, Baer JW, Kotler DP. Pill-induced intramural esophageal hematoma. JAMA. 1987. 257:929.

9. Ashman FC, Hill MC, Saba GP, Diaconis JN. Esophageal hematoma associated with thrombocytopenia. Gastrointest Radiol. 1978. 3:115–118.

10. Yamashita K, Okuda H, Fukushima H, Arimura Y, Endo T, Imai K. A case of intramural esophageal hematoma: complication of anticoagulation with heparin. Gastrointest Endosc. 2000. 52:559–561.

11. Hsu CC, Changchien CS. Endoscopic and radiological features of intramural esophageal dissection. Endoscopy. 2001. 33:379–381.

12. Van Laethem JL, Devière J, Cremer M. Serial endoscopic findings of spontaneous intramural hematoma of the esophagus. Endoscopy. 1997. 29:44–46.

13. Modi P, Edwards A, Fox B, Rahamim J. Dissecting intramural haematoma of the oesophagus. Eur J Cardiothorac Surg. 2005. 27:171–173.

14. Bejvan SM, Godwin JD. Pneumomediastinum: old signs and new signs. AJR Am J Roentgenol. 1996. 166:1041–1048.

15. Akman C, Kantarci F, Cetinkaya S. Imaging in mediastinitis: a systematic review based on aetiology. Clin Radiol. 2004. 59:573–585.

16. Carrol CL, Jeffrey RB Jr, Federle MP, Vernacchia FS. CT evaluation of mediastinal infections. J Comput Assist Tomogr. 1987. 11:449–454.