Esophageal Hematoma Clinical Presentation

Updated: Dec 09, 2016
  • Author: Jennifer Lynn Bonheur, MD; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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Presentation

History

Spontaneous intramural hematoma of the esophagus usually presents initially with severe retrosternal or epigastric pain with or without radiation. The pain is described as abrupt in onset and is aggravated by swallowing.

In one meta-analysis, 32% of patients presented with the triad of chest pain, hematemesis, and dysphagia; 99% of patients had at least one of these symptoms.

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Physical

A complete and thorough physical examination should be performed.

Asking a patient to take a sip of water as part of the general examination may help to unmask symptoms of dysphagia. This may help toward distinguishing between cardiac chest pain and an esophageal disorder causing chest pain.

Palpation looking for the presence of crepitus (suggesting the presence of air under the skin) along the neck, back, and chest can help to rule in or out the presence of an esophageal perforation.

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Causes

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:

  • Coagulopathies, such as hemophilia, or treatment with anticoagulants or aspirin

  • Instrumentation, such as with endoscopy or variceal sclerotherapy

  • Foreign body ingestion

  • Chest trauma

  • Food-induced injury, as a result of abrasive trauma by foodstuffs

  • Cardioversion and subsequent anticoagulation

  • Toxin ingestion

  • Endotracheal intubation

One study reported on 3 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. [18]

A prospective study by Kumar et al indicated that transesophageal echocardiography (TEE)-guided atrial fibrillation (AF) 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% (three 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). [19]

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