Background
Esophageal hematoma is a rare condition that can be spontaneous [1, 2, 3, 4, 5, 6, 7, 8, 9] or secondary to trauma, toxic ingestion, or medical intervention. [10, 11, 12, 13]
Marks and Keet reported a case of a spontaneous intramural hematoma of the esophagus in 1968. [14] This uncommon condition has now been well documented in the literature.
Pathophysiology
Vomiting can lead to increased intraesophageal pressure that may result in mucosal tears (Mallory-Weiss syndrome), transmural perforation (Boerhaave syndrome), or intramural hematoma of the esophagus. The hemorrhage occurs within submucosal tissues. [15, 16]
Intrinsic esophageal disease, such as achalasia, is rare in patients with esophageal hematoma.
Esophageal hematoma may occur at various sites of the esophagus. The mechanism producing the hematoma may determine the site. For example, a hematoma from vomiting would be in the region of the esophagogastric junction, and a hematoma from a caustic substance might be at points of narrowing.
Etiology
Esophageal hematomas typically occur in the setting of vomiting or retching, although spontaneous hematomas (more commonly in patients with bleeding disorders) may also occur.
Precipitating or predisposing factors to esophageal hematoma include the following:
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Coagulopathies, such as hemophilia, or treatment with anticoagulants or aspirin
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Instrumentation, such as with endoscopy or variceal sclerotherapy
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Foreign body ingestion
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Chest trauma
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Food-induced injury, as a result of abrasive trauma by foodstuffs
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Cardioversion and subsequent anticoagulation
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Toxin ingestion
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Endotracheal intubation
One study reported on three patients who developed intramural esophageal hematoma while on hemodialysis. Onset was sudden and characterized by progressively worsening dysphagia and hematemesis. The patients were successfully managed conservatively, with the hematoma resolving within 2-3 weeks. [17]
A prospective study by Kumar et al indicated that transesophageal echocardiography (TEE)-guided atrial fibrillation (AF) ablation is, in rare cases, associated with esophageal hematoma, a cause of significant morbidity. In the study which involved 1110 TEE-guided AF ablation procedures, the procedural incidence of esophageal hematoma was 0.27% (3 procedures). The patients’ predominant symptoms, which arose within 12 hours of the procedure, were hoarseness, odynophagia, and regurgitation. Long-term sequelae of esophageal hematoma included the formation of esophageal strictures, as well as persistent esophageal dysmotility (in association with midesophageal hematoma) and hoarseness caused by vocal cord paralysis (in association with upper esophageal hematoma). [18]
Epidemiology
Sex- and age-related demographics
Approximately 80% of intramural hematomas occur in women. [19]
Primarily middle-aged women are affected. In a literature review of 31 patients, the mean age was 67 years.
Prognosis
Long-term results are very good with conservative and supportive treatment. Intermittent odynophagia usually subsides within 2 weeks after the primary event. Recurrence is extremely rare.
Morbidity/mortality
If the hematoma is associated with a perforation of the esophagus, septic complications (eg, mediastinitis, abscess formation) are likely to occur.
The mortality rate associated with esophageal perforations is about 10-20%. [20]
Complications
Full-thickness perforations of the esophageal wall have been reported during endoscopy of an esophageal hematoma.
