THE NEW ZEALAND MEDICAL JOURNAL Journal of the New Zealand Medical Association
The pink lady Ricardo Jurawan, Malcolm Arnold An 82-year old, usually independent lady presented with a sudden onset of throat pain and odynophagia. She also complained of a sticking sensation in her throat and presented to hospital after the pain radiated to the left parasternal region and epigastrium. Although she felt nauseated there was no vomiting or retching episodes. She was initially given aspirin, nitrolingual spray, and morphine by the paramedics who noted that she became sweaty and hypotensive. She had a normal gastroscopy in July 2005 for investigation of persistent dyspepsia, which had subsequently resolved. She was on aspirin and bendrofluazide for a previous posterior circulation stroke. Her ECGs and cardiac markers (including a troponin value) were negative. She was otherwise well. She had episodes of coffee-ground vomitus and was initially started on intravenous proton pump inhibitors and given fluid resuscitation. A gastroscopy was subsequently performed which showed a large submucosal haematoma extending from the 20 cm mark on the posterior oesophageal wall to the level of the oesophagogastric junction (see images below).
NZMJ 6 June 2008, Vol 121 No 1275; ISSN 1175 8716 URL: http://www.nzma.org.nz/journal/121-1275/3097/
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Questions and answers How common is spontaneous oesophageal haematoma? Rare disease but can occur as a complication of sclerotherapy for oesophageal varices, anticoagulation therapy, or foreign body ingestion. It can also occur spontaneously as in this case.1,2 It is most common in middle-aged patients and twice as common in females as in males.3 What is the anatomy of this haematoma? The position of the haematoma is thought to lie beneath the relatively weak attachment of the mucosa to the muscularis propria.4 What are some differentials? 1. Mallory Weiss tear where vomiting precedes haematemesis and there is a short-segment mucosal tear in the distal oesophagus.5 2. Boerhaave’s syndrome which is a short segment transmural tear affecting the distal oesophagus.6 In addition there is a male preponderance in both Mallory Weiss and Boerhaave’s syndrome. 3. Oesophageal varices.5 4. Cardiac-type pain or aortic dissection.7 What are the initial investigations? Plain chest X-rays which can show mediastinal shadowing or pleural effusion which may suggest oesophageal rupture. Barium swallow which shows an irregular mucosal outline and narrowing or displacement of the oesophageal lumen.5 Gastroscopy with the possibility of visualising intramural tears but with the risk of iatrogenic perforation.8 CT or MRI scan with the advantage of a short scanning time with helical CT and being able to precisely delineate the extent of haematoma. MRI is more accurate for dating the haematoma but has the disadvantage of a longer examination time and associated artefacts from cardiac and respiratory movements.5 What is the management plan? The natural history for such an alarming presentation is benign. The best intervention is non-intervention. Anti-ulcer medications have no clinical benefit9 and supplemented nutrition by parenteral or enteral means and hydration is all that is required. Complete resolution is usual in 7–14 days.5
NZMJ 6 June 2008, Vol 121 No 1275; ISSN 1175 8716 URL: http://www.nzma.org.nz/journal/121-1275/3097/
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Surgical options? Only if there is uncontrolled arterial bleeding or if partial rupture has been converted to a full rupture.9 Another indication for surgery is if there is a focus of infection within the false lumen where endoscopic division of the overlying mucosal flap can ameliorate symptoms.7,10
Outcome Our patient was started on tranexamic acid and proton pump inhibitors. She was weaned onto a soft diet and is due to be rescoped in 4 weeks. She was also tried on a local concoction of the "Pink Lady" which is Mylanta 20 ml mixed with 10 ml xylocaine viscous (2%), 10–20 ml tds/prn, for discomfort with good symptomatic benefit. She is not on aspirin or NSAIDs until her repeat gastroscopy, and we expect a full resolution of her haematoma. Author information: Ricardo Jurawan, Gastroenterology and Internal Medicine Registrar; Malcolm Arnold; Hawke's Bay Hospital, Hawke’s Bay District Health Board, Hastings Correspondence: Dr Ricardo Jurawan, Gastroenterology and Internal Medicine Registrar, Hawke’s Bay Hospital, Private Bag 9014, Hastings, New Zealand. Email:
[email protected] References: 1.
Mosimann F, Bronnimann B, Intramural haematoma of the oesophagus complicating sclerotherapy for varices. Gut. 1994; 35: -1. 2. Meulman N, Evans J, Watson A, Spontaneous intramural haematoma of the oesophagus: A report of three cases and review of the literature. Aust NZ J Surg. 1994;64:190–3. 3. Nagai T, Torishima R, Nakashima H, et al. Spontaneous esophageal submucosal haematoma in which the course could be observed endoscopically. Intern Med. 2004;43:461–7. 4. Atefi D, Horney JT, Eaton SB, et al. Spontaneous intramural haematoma of the esophagus. Gastrointest Endosc. 1978;24:172–4. 5. Yuen EHY, Yang WT, Lam WWM, et al. Spontaneous intramural haematoma of the oesophagus: CT and MRI appearances. Australasian Radiology. 1998;42:139–42. 6. Bradley SL, Pairolero PC, Payne S, Gracey DR. Spontaneous rupture of the esophagus. Arch Surg. 1981;116:755–8. 7. Bak YT, Kwon OS, Yeon JE, et al. Endoscopic treatment in a case of dissection of the oesophagus. Eur J Gastroenterol Hepatol. 1998;10:969–72. 8. Skillington PD, Matar KS, Gardner MA, et al. Intramural haematoma of the oesophagus complicated by perforation. Aust NZ J Surg. 1989;59:430–2. 9. Cullen SN, McIntyre AS. Dissecting intramural haematoma of the oesophagus. Eur J Gastroenterol Hepatol. 2000;12:1151–61. 10. Murata N, Kuroda T, Fujino S, et al. Submucosal dissection of the oesophagus; a case report. Endoscopy. 1991;23:95–7.
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