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| Journal of the New Zealand Medical Association,
01-December-2006, Vol 119 No 1246
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Spontaneous submucosal haematoma of the
oesophagus
Jeremy Rossaak, Christopher Wakeman, Grant Coulter
Submucosal oesophageal haematoma is a rare disease, most
commonly encountered as a complication of sclerotherapy for oesophageal
varices.1 However, it has also been described
as occurring in patients with
coagulopathy,2–4 foreign body
ingestion, or (spontaneously) related to swallowing or
vomiting.4
We present a series of patients recently seen in our
department to illustrate the typical features of this disease and review the
literature.
Case reportsCase 1—This 80-year-old female
presented with sudden onset of chest pain radiating through to her back, which
started as she finished a cup of tea. It was constant and described as a
dull pain. There was associated nausea and vomiting, but no haematemesis. There
was no history of dysphagia, reflux symptoms, or regurgitation.
She maintained good health despite mild hypertension
(controlled with cilazapril), hypercholesterolaemia (controlled with
simvastatin), and glaucoma. She took 100 mg aspirin a day for cardiac
protection. On examination she was haemodynamically stable, with a soft
abdomen.
Haemoglobin on admission was 133 g/L, dropping to 115 g/L on
the day post admission, before stabilising at 100 g/L on day 2. The platelet
count was 191 × 109/L. INR was 1.1 and
APPT 28 sec. The potassium was elevated at 5.4 mol/L and urea at 14.9 mmol/L
with a creatinine of 0.12 mmol/L, consistent with an upper gastrointestinal
bleed. The liver function tests were within the normal range.
Her investigations included a computed tomography (CT) scan
and a gastroscope (Figures 1-4).
Figure 1. Arterial phase CT scan at the level
of T12, showing a dilated oesophagus with an air meniscus anteriorly in the
oesophagus (single arrow) and contrast in the aorta (double
arrow)
 Figure 2. Arterial phase lateral CT scan
demonstrating an oesophageal dilatation from the oropharynx to the diaphragm
(double arrow), with narrowing of the oesophagus as it passes through the
diaphragm. A contrast blush consistent with arterial bleeding at the time of the
CT scan is visible in the upper oesophagus (single arrow)
 Figure 3. Endoscopic view of the oesophagus,
demonstrating the blue discoloured haematoma extending down the posterior wall
(arrowed)
 Figure 4. Incidentally, the patient also had
gastric ulcers (arrowed).
 Case 2—A 77-year-old male was
referred acutely with a history of dry retching, followed by haematemesis with
associated epigastric pain. There was no syncope or malaena. His medical illness
included non-insulin dependant diabetes mellitus, peripheral neuropathy,
emphysaema, and diverticular disease. He took regular aspirin in addition to his
oral hypoglycaemics.
Examination revealed a haemodynamically stable
patient—pulse 97/min and blood pressure 132/100 mmHg. Abdominal
examination was unremarkable and there was no malaena on rectal examination. On
admission, his haemoglobin was 117 g/L, platelets 140 ×
109/L, and an INR 1.1, with an APPT of 27
seconds.
He was investigated with a gastroscope and CT scan. The
gastroscopy was diagnostic for a large submucosal haematoma (Figure 5).
Figure 5. Endoscopic view of the submucosal
haematoma starting at 25 cm from the incisors, extending to the
gastro-oesophageal junction (arrowed)
 The CT scan confirmed a 65 mm × 50 mm × 140 mm
mass in the posterior mediastinum extending from the carina inferiorly
consistent with the oesophagus.
The day after admission he developed increasing dysphagia,
tolerating fluids only. His haemoglobin dropped to105g/L and a repeat
gastroscopy on day 15 post admission showed the haematoma had ruptured,
resulting in a well healed longitudinal ulcer (Figure 6).
Figure 6. Endoscopic view of the healed
longitudinal ulcer (arrowed).
 The patient’s hospital stay was prolonged and
complicated by pneumonia.
Case 3—A 59-year-old female presented
with a 2-day history of epigastric and retrosternal pain, exacerbated by
swallowing. There was no history of haematemesis or malaena.
Her medical illness included diabetes mellitus (for which
she was on insulin), cerebrovascular disease, ischaemic heart disease,
congestive cardiac failure, hypertension, gastro-oesophageal reflux disease, and
abdominal pain suspected of being related to sphincter of Oddi dysfunction. Her
medications included warfarin for stroke protection and aspirin.
On admission, her haemoglobin was 126 g/L, platelets of 219
× 109/L, and the INR was 4.8.
Gastroscopy demonstrated a typical submucosal haematoma of
the oesophagus.
She was stabilised in hospital and discharged with an INR of
2-2.5.
She was readmitted 5 months later with epigastric pain and
dysphagia. There had been no haematemesis or malaena. The haemoglobin was 139g/l
with an INR of 4.0.
The gastroscopy demonstrated a single epithelialised ulcer
at 29 cm (Figure 7).
Figure 7. Oesophageal linear ulcer at 29 cm
(arrowed).
 Case 4—A 69-year-old female was
admitted with unstable angina. She was commenced on therapeutic enoxaparin and
aspirin. She later developed retrosternal chest pain, exacerbated by swallowing.
There was no haematemesis or malaena.
A gastroscope demonstrated a small submucosal haematoma at
33 cm from the incisors (Figure 8).
Figure 8. Submucosal haematoma
(arrowed).
 DiscussionWe have presented four patients with spontaneous submucosal
haematomas of the oesophagus to demonstrate some of the features of this
disease, and have reviewed the literature to explain some of these findings. Two
patients developed the haematomas whilst anticoagulated, one related to vomiting
and the other to swallowing.
The condition is nearly twice as common in females compared
to males (1.8:1) and occurs in middle aged
patients.5
The aetiology of this condition is related to a sudden
change in the intraoesophageal pressure, as occurs with vomiting or swallowing
with in coordinated oesophageal movement. The first case presented, and other
patients have been noted to be eating or drinking at the onset of
pain.4,6–8 However vomiting has also been
proposed, as in the second case, through oesophageal
hyperpressure.8–10
Some authors have described spontaneous oesophageal
haematoma as an intermediate stage between Boerhaave’s syndrome and a
Mallory-Weiss tear, although there are fundamental differences between these
entities, for example forceful vomiting is not always a feature of spontaneous
oesophageal haematoma.8
Others may have a bleeding diathesis or be on an
anticoagulant3,11,12 and trauma forms a group
of patients.13 Cases 3 and 4 were
anticoagulated.
Anatomically the haematoma is normally identified in the
distal oesophagus as this is the area least supported by the adjacent
structures, the heart and trachea.14 The
haematoma has been reported in one study to lie between the circular and
longitudinal muscles of the oesophagus,2
however considering the structure of the oesophagus, with the mucosa being
weakly attached to the muscularis propria, a submucosal situation would seem
more likely and is the accepted position of the
haematoma.15–17
Clinically the condition is associated with chest pain or
epigastric pain of sudden onset, that may radiate to the back and may be
difficult to differentiated from cardiac pain, major vessel dissection or
oesophageal rupture.18 There is often
associated sweating and tachycardia, consistent with severe pain and odonophagia
or dysphagia may be present.18 Thirty-five
percent of patient present with a triad of retrosternal chest pain, dysphagia,
and haematemesis,19 and 80% have two of
these features.20
Computed tomography (CT) scanning is sensitive and specific
for oesophageal pathology, and can be diagnostic. The characteristic features
are a dilated oesophagus containing a homogenous density greater than water, and
a meniscus at the air lumen mucosa
interface.21,22
The endoscopic findings are typical with a blue submucosal
haematoma bulging into the oesophageal mucosa.5
Other diagnostic tools include magnetic resonance imaging (MRI), however this
form of imaging may be complicated by movement artefact. Typically, the MRI
findings are of a posterior mediastinal mass with intermediate signal intensity
on T1- and T2-weighted images with scattered areas of high
signal intensity within the mass.2,21
Transoesophageal ultrasound gives excellent views of the
oesophagus, however the probe is placed blind and may traumatise the
oesophagus.
The prognosis is good14
with patients tolerating a fluid or soft diet as soon as the dysphagia
passes. The haematoma resolves in 7 days,5,19
leaving a shallow ulcer. Occasionally severe bleeding or perforation may
occur.20
ConclusionThis paper describes four cases of spontaneous oesophageal
haematoma, identifying anticoagulant therapy as a major risk factor. The
management is all cases was conservative, with good results. A review of the
literature supports conservative management of this condition.
Author information: Jeremy Rossaak,
Surgical Registrar; Christopher Wakeman, Surgical Registrar; Grant Coulter,
Surgeon; Department of General Surgery, Christchurch Hospital,
Christchurch
Correspondence: Dr Chris Wakeman, Surgical
Registrar, Department of General Surgery, Christchurch Hospital, PO Box 4345,
Christchurch. Email: Christopher.Wakeman@cdhb.govt.nz
References:
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