Intramural oesophageal dissection as an unusual presentation of chest pain: A case report

Abstract

IntroductionIntramural oesophageal dissection (IOD) is a rare clinical condition and there is a paucity of information regarding the appropriate diagnosis and management. It is described as bleeding in the submucosal plane of the oesophagus, and has various documented causes.Presentation of caseWe report a case of a 73 year old female who developed IOD. She presented with severe chest pain. Subsequent imaging revealed IOD and haematoma formation. This was confirmed on oesophagogastroduodenoscopy (OGD). She was on a bisphosphonate for her osteoporosis, as well as having age-related dysmotility of her oesophagus on manometric studies. She was also taking fish oil. Treatment was conservative and the patient was discharged with proton pump inhibitors and follow up.DiscussionSpontaneous haematoma formation and IOD resulted likely from a combination of the anticoagulant effect of fish oil and oesophageal dysmotility. Bisphosphonates also have some well documented gastrointestinal side effects involving mucosal damage. The possibility that the concurrent use of bisphosphonate led to a pre-existing ulcer which could have contributed to the development of IOD in this patient should be considered.Conclusionspontaneous IOD can occur in elderly patients who are anticoagulated. Fish oil has not been previously reported as having an association with IOD. This is the first known reported case of spontaneous IOD occurring in association with concurrent use of a bisphosphonate and fish oil. IOD is a rare disorder, and any anticoagulated patients presenting with severe chest pain may need careful investigation prior to definitive management.

Multiple esophageal hematomas with oozing observed and successfully treated after transcatheter mitral valve edge‐to‐edge repair procedure

“…We believe that the frequency of hematomas has reduced owing to careful endoscopy procedures and less time required for performing them in recent times. Previous reports revealed that chest pain, dysphagia, and hemorrhage cause esophageal hematomas, and these hematomas spread extensively from the upper to the lower esophagus 5,7–9 . Moreover, an ulcer was formed in the process, but resolved on treatment after a few weeks 7,9 .…”

“…Previous reports revealed that chest pain, dysphagia, and hemorrhage cause esophageal hematomas, and these hematomas spread extensively from the upper to the lower esophagus. 5 , 7 , 8 , 9 Moreover, an ulcer was formed in the process, but resolved on treatment after a few weeks. 7 , 9 In the present cases, hemispherical and relatively small hematomas tended to develop at multiple sites.…”

“… 5 , 7 , 8 , 9 Moreover, an ulcer was formed in the process, but resolved on treatment after a few weeks. 7 , 9 In the present cases, hemispherical and relatively small hematomas tended to develop at multiple sites. This was possibly because we actively selected mild cases showing a trace of blood on the TEE probe and performed endoscopy immediately after.…”

“…Till date, esophageal hematoma has been referred to using different names, including esophageal hematoma, 1 dissecting intramural hematoma, 2 intramural hematoma of the esophagus, 7 esophageal submucosal hematoma, 8 intramural esophageal dissection. 9 These terms refer to the same illness of submucosal hematoma. As for the esophageal structure, vessels going through the muscular layer form a dendritic vascular plexus around the muscular layer of the mucosa.…”