Spontaneous intramural rupture and intramural haematoma of the oesophagus.

Abstract

Spontaneous intramural rupture or intramural haematoma of the oesophagus is a rare cause of acute pain in the chest and upper abdomen. Much less ominous than spontaneous complete rupture from which it must be distinguished, it seldom if ever necessitates operation. Five new cases are described and reviewed together with 15 collected from published reports. The dominant symptom of every case was severe and constant retrosternal or epigastric pain; concomitant dysphagia was mentioned in 11 cases. In seven the pain was preceded by or coFincided with vomiting. The condition was related to other stresses in three and appeared to be truly spontaneous in 10. In approximately one-third of cases it started suddenly but more often it began as discomfort worsening rapidly. Fourteen patients vomited blood after experiencing pain but only four were given transfusions. In contradistinction to complete rupture, none had surgical emphysema and plain chest radiographs were unremarkable. All had abnormal gastrografin or barium swallows. Intramural haematomas with or without mucosal tears were seen in the 11 cases in which oesophagoscopy was performed. Fifteen patients made rapid and complete recoveries on conservative management. Of the four who did not respond satisfactorily, one had the oesophagus repaired, two had drainage of the mediastinum after failure to find the false lumen at thoracotomy, and one had only an abdominal exploration. The only death in the whole series occurred after a disastrous emergency exploration and subsequent total oesophagectomy.The first editor of Thorax wrote for the first issue of this journal the article that was largely responsible for transforming spontaneous perforation or rupture of the oesophagus, the Boerhaave syndrome, from a little-known necropsy finding to a generally recognised clinical entity.' After describing the symptoms and signs by which the diagnosis could and should be made during life, Barrett argued that immediate repair was the logical method of treatment and offered the best hope of survival, and a year later he himself had the satisfaction of proving his thesis by recording the first succesful operation for that catastrophic condition.2 While there can be few nowadays who would recomend conservative management for

A case of spontaneous submucosal dissection of the esophagus

“…Surgical therapies [2,4,12,14], and endoscopic treatments such as cutting of the mucosal bridge using an endoscopic diathermy snare knife [3], have been recommended for recurrent or intractable disease [6]. A balloon tamponading method using a SengstakenBlackmore tube was reported to treat a mucosal false lumen [6].…”

“…Inspection thoracotomy was commonly done for diagnosis of transmural esophageal perforation or for the cause of severe pain and/or swallowing disabilities [4,8,14]. However, one case underwent esophagomyotomy 2 years after onset as a result of esophageal stenosis with chest pain on swallowing [14].…”

Dissection of the esophagus after dilatation of a cervical diaphragm

“…The esophageal dissection instead is usually controlled by conservative treatment [4,8,9, 14] consisting of(l) discontinuing oral alimentation, (2) starting a program of total parenteral nutrition, (3) naso-gastric suctioning, and (4) antibiotic treatment.…”

Intramural hematoma of the esophagus caused by minor head injury 6 hours previously

“…In a literature review by Kerr in 1980 only 20 of these cases are reported [3]. Esophageal trauma most frequently is inflicted by ingested substances (e.g., fish bones) or fierceful retching and vomiting, all leading to a dramatic increase of the intraluminal esophageal pressure.…”