Intramural esophageal hematoma after elective injection sclerotherapy

Abstract

-Context -Although endoscopic esophageal variceal sclerotherapy has been largely supplanted by variceal band ligation, it is still performed routinely in many institutions, especially in developing countries. Intramural esophageal hematoma has been described as a rare complication of sclerotherapy. Risk factors have not been completely established. Objective -To demonstrate the incidence of post-sclerotherapy intramural esophageal hematoma in our hospital and discuss the possible factors involved. MethodsThis is a retrospective observational study made at the "Hospital Universitário Clementino Fraga Filho", Rio de Janeiro, RJ, Brazil, reviewing the medical records of all esophageal variceal sclerotherapy procedures performed from April 2000 to November 2005. The evaluation of the clinical, laboratorial and endoscopic features in our patients and those reported in the literature was also done. Review of literature was performed through MEDLINE search. Results -A total of 1,433 esophageal variceal sclerotherapy procedures were performed in 397 patients, with an intramural esophageal hematoma incidence of 4 cases (0.28%). Three of our patients developed additional complications, and one death was a direct consequence of a rupture of the hematoma. Nineteen well described cases were reported in the literature. Intramural esophageal hematoma occurred mostly after the forth esophageal variceal sclerotherapy session. Coagulation disturbances were present in the majority of cases. Conclusion -Intramural esophageal hematoma is a rare complication of esophageal variceal sclerotherapy and its incidence in our institution was similar to those observed in the literature. Our study suggests that this complication occurs as a result of a fragile esophageal mucosa after previous esophageal variceal sclerotherapy sessions. Impaired coagulation, although not essential, could contribute to hematoma formation and extension through esophageal submucosa.

Intramural Esophageal Hematoma With Associated Hemothorax

“…IEH may be caused by trauma, such as food impaction/foreign body ingestion, 5 , 6 or iatrogenically after instrumentation. Although uncommon, IEH has been reported after NGT placement, 1 esophageal variceal sclerotherapy, 7 and cold forceps biopsy by EGD. 8 It can also occur spontaneously after barotrauma or in the setting of coagulation disorders or the use of anticoagulation/antiplatelet therapy.…”

Large Esophageal Intramural Hematoma After Solid Food Ingestion in a Patient Without Identifiable Inherited or Acquired Coagulopathy

“…DIHE has been reported in the setting of warfarin use with a therapeutic international normalized ratio of 2.5, 3 chronic idiopathic thrombocytopenia, 4 hemophilia A, 5 herpes esophagitis, 6 trauma from food ingestion, 7 trauma from cardioversion, 8 acquired factor XI deficiency in a patient with relapsed T-cell prolymphocytic leukemia after allogenic hematopoietic-cell transplantation, 9 esophageal duplication cyst, 10 after surgical delivery of preterm twins in a preeclamptic woman on therapeutic enoxaparin due to multiple venous thromboembolism risk factors, 11 and after injection sclerotherapy. 12 Most cases are benign and are effectively treated with conservative measures with resolution of symptoms typically within 1-2 weeks. 13 Conservative measures include nothing by mouth, intravenous fluid resuscitation, acid suppression with proton pump inhibitors, and correction of any coagulopathies if present.…”

“…DIHE has been reported in the setting of warfarin use with a therapeutic international normalized ratio of 2.5, 3 chronic idiopathic thrombocytopenia, 4 hemophilia A, 5 herpes esophagitis, 6 trauma from food ingestion, 7 trauma from cardioversion, 8 acquired factor XI deficiency in a patient with relapsed T-cell prolymphocytic leukemia after allogenic hematopoietic-cell transplantation, 9 esophageal duplication cyst, 10 after surgical delivery of preterm twins in a preeclamptic woman on therapeutic enoxaparin due to multiple venous thromboembolism risk factors, 11 and after injection sclerotherapy. 12 …”