An 85-year-old female with a history of AF was prescribed dabigatran. She presented to the emergency department with haemoptysis following ingestion of her first tablet. During swallowing she felt an unusual sensation in her throat causing her to cough and regurgitate. She then developed odynophagia. She woke up the next day complaining of haemoptysis and shortness of breath. She was taking no other antiplatelet or anticoagulants.

Her haemoglobin was 114g/L and her coagulation markers were normal. CXR with lateral neck soft tissue showed a rounded opacity at the level of the hyoid posteriorly consistent with the ingested tablet and demonstrated signs consistent with congestive cardiac failure.

She was admitted under the medical team who investigated her for the possibility of a pulmonary embolus. Computed topography showed a filling defect in the oesophageal lumen on the lateral aspect of the oesophagus consistent with an oesophageal haematoma. A gastroscopy was performed five days after presentation, which showed an oesophageal mucosal tear and underlying haematoma. On referral to the general surgical team a repeat CT chest with oral contrast was performed to exclude oesophageal perforation. It confirmed the diagnosis and that the haematoma was already resolving.

Patient was treated conservatively with reintroduction of diet and recovered uneventfully.

Discussion

Intramural haematoma of the oesophagus is a rare disease where a rupture of blood vessels in the submucosal layer haemorrhage and cause the formation of haematoma.1 Underlying vessel fragility with an insult is thought to be the predisposing pathophysiology. The location of the haematoma is submucosal due to the weak attachment of the muscularis propria. The presentation of oesophageal haematoma consists of the triad of haematemesis, retrosternal pain and dysphagia/odynophagia. Eighty percent of patients will have two-thirds of the triad, while only 32–35% will have all three.2,3,4 Risk factors are middle age, female (RR1.8+++), a history of vomiting or coughing and foreign body ingestion.2,4 Patients without precipitating factors are more likely to have coagulation abnormalities such as idiopathic thrombocytopenic purpura or be using anticoagulant therapy.4

Intramural haematoma of the oesophagus must be differentiated conceptually from Boerhaaves syndrome and Mallory-Weiss tears. Boerhaaves syndrome is a full thickness oesophageal perforation, due to barogenic injury from forceful vomiting or retching with sudden increase in intra-abdominal pressure.4 The main symptom is chest pain with an appropriate history; conversely, patients who present with shock are difficult to diagnose as they are less likely to have a classic history.4 They must be managed aggressively to control mediastinal contamination.

Mallory Weiss tears are a shear injury to the oesophageal mucosa. They occur when abrupt upward diaphragm movement along with rapid increase of intra-abdominal pressure causes the gastric cardia to move through the hiatus into the thoracic cavity. This results in a longitudinal laceration, which is likely to arise at the point of maximal dilatation (Laplace’s law), which is usually within 2cm of the cardia on the lesser curvature.4 Alternatively, 10% of patients will present with melena and 10% with shock.4

Computed topography with oral contrast is both sensitive and specific for IHE and can exclude other differentials such as Boerhaave’s syndrome, aortic dissection or aneurysms.2,4 Contrast studies can also be used to exclude perforation. Gastroscopy is useful to confirm the diagnosis of oesophageal haematoma and further assess the condition of the oesophagus. Treatment of suspected oesophageal haematoma is 1) to exclude full thickness oesophageal perforation and 2) manage conservatively as most haematomas/tears resolving spontaneously. On occasion, nasojejunal feeding or total parenteral nutrition may be needed to maintain nutrition in the short-term while awaiting resolution of the haematoma.5 In our patient, oral diet was able to be reintroduced immediately. Complications of oesophageal haematoma are rare but include severe bleeding or oesophageal perforation from pressure effects of the haematoma on the oesophageal wall.2

With the ever-increasing availability of cross-sectional imaging, intramural haematoma of the oesophagus will be diagnosed more often. It is an under-recognised condition which is important to be aware of, as exclusion of oesophageal perforation is mandatory, but subsequent management is conservative and prognosis is excellent.

Figure 1:  

A—Coronal view of the haematoma. It can be seen on the left side of the oesophagus.
B—CT scan showing soft tissue mass on the left oesophageal wall.
C—Lateral x-ray showing residual tablet at posterior aspect of hyoid.
D—Three days later from A showing resolution of haematoma.
E and F—Middle third of oesophagus showing large, elongated haematoma and ulceration. F shows the residual tablet at the distal end of the oesophagus.

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