Esophageal Hematoma Workup

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

Laboratory Studies

The laboratory workup should include hemoglobin concentration and coagulation profile with platelet count.

Cardiac enzymes and troponin levels should be drawn to exclude a cardiac cause for the patient's chest pain.

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Imaging Studies

Chest radiograph

Chest radiographs may reveal a broadened mediastinal mass or bilateral pleural effusions. Preliminary study helps to exclude a perforation and other pathologies included in the differential diagnosis of chest pain.

Barium swallow (esophagram)

Typically, this study helps to confirm the diagnosis, revealing a filling defect in the mid and lower esophagus, usually on the posterior wall, with luminal narrowing and sometimes with mucosal irregularity. Extravasation into the mediastinum is not observed unless a perforation has occurred.

A double barrel sign or a mucosal stripe sign may be demonstrated, that is, double columns of contrast medium separated by a radiolucent stripe and a large intramural mass that reflects a mucosal dissection that allows extravasation of contrast material into the hematoma.

Computed tomography (CT) scanning with contrast

CT scanning reveals a nonenhancing, eccentric, well-defined, intramural esophageal mass that has the density of blood. It can help to better characterize esophagram findings, accurately define the extent of intramural dissection, and exclude esophageal perforation.

CT scanning is useful in excluding other conditions that may mimic esophageal hematoma, including mass lesions, aortic dissection, and pulmonary embolism.

Magnetic resonance imaging (MRI)

MRI can help demonstrate the extent of the hematoma in various planes and can help rule out additional mediastinal pathology. It is indicated for patients who cannot have a CT scan because of an allergy to iodinated contrast medium or renal impairment.

Endoscopic ultrasonography (EUS) 

An endoscopic ultrasound (EUS) shows an intramural hypoechoic submucosal mass.

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Procedures

Upper endoscopy

It has been suggested that fiberoptic endoscopy is relatively contraindicated in the further evaluation of esophageal hematoma because many intramural hematomas are contained perforations that could be worsened by the insufflation of air. Others endorse the use of endoscopy in the initial evaluation once esophageal perforation has been ruled out.

Endoscopically, an esophageal hematoma is described as a bluish or purplish colored, submucosal mass protruding into the esophageal lumen.

Endoscopy can precisely identify the tear in the mucosa, but the risk of the procedure should be weighed against the need for this information and the generally uncomplicated course that these patients follow.

Flexible esophagoscopy

Flexible esophagoscopy may be a possible diagnostic tool in patients with traumatic esophageal injuries. Arantes et el evaluated the use of this technique in a retrospective (1998-2003) and prospective (2003-2005) study. One hundred sixty-three Findings from flexible esophagoscopy were compared with surgical findings or clinical follow-up in 163 patients with clinical suspicion of esophageal trauma (ie, laceration/perforation, hematoma, abrasion, hematin spots, ecchymosis) assessed. [20] No esophageal lesions were seen in 139 patients (85.3%), but 23 (14.1%) examinations demonstrated esophageal injuries, and 1 (0.6%) case was inconclusive (esophageal stricture). [20] There was surgical confirmation of lacerations in 14 patients. Of 9 patients with observed esophageal contusion, 5 underwent surgical exploration and 4 were managed nonoperatively. The investigators reported flexible esophagoscopy had 95.8% sensitivity, 100% specificity, 99.3% accuracy, 100% positive predictive value, and 99.2% negative predictive value in assessing esophageal injury. [20]

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