Intramural esophageal hematoma after endoscopic injection sclerotherapy for bleeding varices

Abstract

Endoscopic variceal sclerotherapy (EVS) is widely used to treat bleeding esophageal varices. A variety of complications have been reported after EVS, including intramural hematoma of the esophagus (IHO), which occurs infrequently. The present report describes four new cases of IHO after EVS and reviews the pathogenesis, diagnosis and treatment of the condition. In addition, 10 patients with IHO after EVS documented in the literature are analyzed. Between 1984 and 2001, 580 patients with bleeding esophageal varices had 5038 endoscopies and underwent a total of 2628 variceal injection sessions. The incidence, presentation and response to conservative management of IHO were evaluated. Four of the 580 patients (0.7%) developed IHO as a complication of EVS. All developed severe retrosternal chest pain, sudden-onset dysphagia and odynophagia after EVS. Diagnosis was confirmed using upper gastrointestinal contrast studies. Patients were kept nil per mouth and received intravenous fluids until able to swallow without difficulty. Symptoms usually began to resolve spontaneously within 36-72 h and disappeared completely in 2-3 weeks. In a patient who has recently had EVS and has a clinical picture compatible with the diagnosis of IHO, contrast studies provide the simplest way of confirming the diagnosis and excluding an esophageal perforation. Treatment of IHO after endoscopic variceal sclerotherapy should be conservative, due to the benign, self-limiting nature of this uncommon complication.

Endoscopic therapy for esophageal hematoma with blue rubber bleb nevus syndrome

“…patient was able to resume eating sooner than might have been predicted based on prior reports [7][8][9][10][11] . Following conservative therapy, symptoms usually begin to resolve 36-72 h after treatment and disappear completely in 2-3 wk [8] .…”

“…Following conservative therapy, symptoms usually begin to resolve 36-72 h after treatment and disappear completely in 2-3 wk [8] . The start of oral intake was sooner than previous cases [9][10][11] .…”

Intramural esophageal hematoma after elective injection sclerotherapy

“…Nineteen well described cases were reported in the literature (1,3,4,6,7,10,12,22,24,25,29) . Eleven were males.…”

“…Sclerosant agents used included ethanolamine 5%, polidocanol 1% to 2% and sodium tetradecyl sulfate 1.5% to 3%. One patient developed a pleural effusion (22) , one had rupture of a hematoma without clinical consequences (17) and two presented a tracheal compression with respiratory insufficiency (1,3) . All cases were managed conservatively, except those complicated by tracheal compression, the treatment of which consisted of an endoscopic incision of the hematoma in one (1) and a tracheal intubation in the other (3) .…”

“…The etiology of cirrhosis was alcoholic in 12, primary biliary in 2, viral hepatitis C in 2, nodular regenerative hyperplasia in 1 and cryptogenic in 1 patient. Prothrombine time varied from 55% to 100% and platelet count varied from 50,000 to 121,000 mm 3 . Sclerosant agents used included ethanolamine 5%, polidocanol 1% to 2% and sodium tetradecyl sulfate 1.5% to 3%.…”