An atypical case of fatal 'esophageal apoplexy': post-mortem findings and differential diagnosis.

Forensic pathologists need to have comprehensive knowledge of a large variety of causes of sudden natural death. We describe a case of sudden and unexpected death in woman in her sixties due to rupture of a large paraesophageal hematoma. The post-mortem examination and differential diagnosis are discussed. The combined findings of whole-body post-mortem CT imaging (PMCT), targeted PMCT angiography, autopsy, and histology are most in keeping with 'esophageal apoplexy'; a rare cause of hemorrhage in the esophageal wall. A review of the literature indicates that most cases of esophageal apoplexy are self-limiting and that fatal complications are exceedingly rare. Our case demonstrates that esophageal apoplexy can present as sudden unexpected death.

The transesophageal echo probe may contribute to esophageal injury after catheter ablation for paroxysmal atrial fibrillation under general anesthesia: a preliminary observation.

INTRODUCTION: The transesophageal echo probe (TEE) is commonly used before and during atrial fibrillation (AF) ablation under general anesthesia (GA). We sought to determine the potential contribution of the TEE probe to esophageal injury after pulmonary vein isolation (PVI) alone for paroxysmal AF. METHODS AND RESULTS: Seventy-six patients undergoing PVI with TEE, PVI/TEE, 16 undergoing PVI without TEE (PVI/No TEE), and 27 undergoing TEE without any left atrial ablation (TEE/No LA ablation) under GA were included. Posterior wall ablation was power (20-25 W) and time limited (electrogram attenuation or ≤30 s). Esophageal capsule endoscopy (n = 206) was performed pre- and post-procedure and at 2 weeks. Esophageal lesions were seen in 30% of PVI/TEE, 0% of patients in the PVI/No TEE (P = 0.009), and 22% of TEE/No LA ablation groups (P = 0.47 vs. PVI/TEE). There were no instances of esophageal bleeding, perforation, or need for gastrointestinal intervention. Self-resolving dysphagia was the only reported symptom (5%). All lesions healed within 2 weeks. There was no significant difference in the location or morphological appearance of esophageal lesions seen in the PVI/TEE versus TEE/No LA ablation groups. CONCLUSIONS: Esophageal lesions were seen in 30% of patients undergoing PVI alone under GA with use of TEE and in a similar proportion (22%) of patients undergoing TEE in the absence of left atrial ablation. This study makes the preliminary observation that one must be cognizant of the TEE probe as a potential contributor to esophageal injury after AF ablation. Larger studies are needed to confirm these findings.

Intramural Esophageal Hematoma With Associated Hemothorax.

Intramural esophageal hematoma (IEH) is a rare manifestation of esophageal wall injury with nonspecific symptoms. It may be caused by trauma or occur spontaneously. IEH is often discovered on computed tomography or esophagogastroduodenoscopy and is typically managed conservatively with supportive care to allow healing. It is frequently an isolated finding in the esophagus and seldom involves any other organ. We report a rare case of a patient discovered to have an obstructing IEH with associated hemothorax after an unrelated surgical admission.

Esophageal hematoma mimicking esophageal varices after chewing betel nut: a case report.

BACKGROUND: Betel nut chewing is very common in Southeast Asia and other tropical countries. Much clinical evidence suggests that chewing betel nut has pro-inflammatory and carcinogenic effects, but there are few clinical reports of acute toxicity caused by it, especially involving esophageal damage. CASE PRESENTATION: We presented a case of a 72-year-old female who was admitted to our hospital for chest pain and hematemesis within several minutes after chewing betel nut. Gastroscopy showed two longitudinal ridge-like mucosal eminences in the esophagus located 20 cm from the incisors down to the gastric cardia, which was similar to varices. At last, a CT scan showed concentric-circle thickening of the esophagus wall, suggesting hematomas. Our treatment included fasting, inhibiting gastric acid and maintaining blood volume. After one week of medical treatment, rechecked gastroscopy showed that esophageal hematomas were gradually absorbed, with the formation of multiple shallow ulcers. CONCLUSIONS: The acute toxicity of chewing betel nut can be easily overlooked. Patients who experience chest pain or hematemesis after chewing betel nut products,especially those who take aspirin at the same time, need to be alert to esophageal hematoma.

Treatment of Esophageal Hematoma After Left Atrial Appendage Occlusion: A Case Report.

Left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulation therapy in patients with atrial fibrillation who are at high risk for bleeding and thromboembolic events. Transesophageal echocardiography (TEE) is the standard modality for intraprocedural imaging during LAAO. We report a rare case of extensive submucosal esophageal hematoma that developed after a TEE-guided LAAO procedure. The cause, management, and prevention of this complication are explored in depth in this report.

Spontaneous Intramural Esophageal Hematoma Secondary to Thrombolysis in the Setting of Pulmonary Embolism.

Intramural hematoma of the esophagus (IHE) represents a rare condition on the spectrum of esophageal injuries. The most common symptoms are hematemesis, epigastric pain or retrosternal chest pains, odynophagia, and dysphagia. Early recognition of IHE is important as it may mimic other diseases such as myocardial infarction, pulmonary embolism, Mallory-Weiss tears, Boerhaave's syndrome, ruptured aortic aneurysms, and aortic dissection. Computed tomography is the preferred investigation method, and treatment is usually conservative. We herein present 2 cases of IHE associated with catheter-directed thrombolysis in the setting of pulmonary embolism.

Esophageal Hematoma Associated with the Bolus Ingestion of Hot Coffee.

A 59-year-old woman presented with pharyngeal discomfort and dysphagia starting the previous day. Esophagogastroduodenoscopy revealed a longitudinal reddish area and hematoma mainly on the left wall of the esophagus. On the previous day, she had felt a piece of meat sticking in her throat while eating; she therefore rapidly gulped down some hot coffee to hasten the passage of the meat. Based on the history, we diagnosed her endoscopic findings as esophageal hematoma and thermal injury associated with hot coffee. We herein describe a case of an acute esophageal hematoma and thermal injury and the clinical course following endoscopy.

Intramural Esophageal Hematoma Secondary to Food Ingestion.

Intramural esophageal hematoma (IEH) is a rare cause of submucosal esophageal bleeding and it is on the spectrum of esophageal wall injury along with mucosal tears (Mallory-Weiss syndrome) and full thickness perforation (Boerhaave's syndrome). Its risk factors include coagulopathy, trauma (foreign body ingestion or esophageal instrumentation) or it can happen spontaneously. It presents with a triad of chest pain, dysphagia, and hematemesis; however, the triad is only present in 35% of patients. We are presenting a case of IEH secondary to food ingestion that was managed successfully by conservative measures.

Endoscopic therapy for esophageal hematoma with blue rubber bleb nevus syndrome.

A 57-year-old woman previously diagnosed with blue rubber bleb nevus syndrome (BRBNS) reported hematemesis. BRBNS is a rare vascular anomaly syndrome consisting of multifocal hemangiomas of the skin and gastrointestinal (GI) tract but her GI tract had never been examined. An upper gastrointestinal endoscopy revealed a large bleeding esophageal hematoma positioned between the thoracic esophagus and the gastric cardia. An endoscopic injection of polidocanol was used to stop the hematoma from bleeding. The hematoma was incised using the injection needle to reduce the pressure within it. Finally, argon plasma coagulation (APC) was applied to the edge of the incision. The esophageal hematoma disappeared seven days later. Two months after the endoscopic therapy, the esophageal ulcer healed and the hemangioma did not relapse. This rare case of a large esophageal hematoma originating from a hemangioma with BRBNS was treated using a combination of endoscopic therapy with polidocanol injection, incision, and APC.

Spontaneous intramural esophageal hematoma (IEH) secondary to anticoagulation and/or thrombolysis therapy in the setting of a pulmonary embolism: a case report.

Intramural esophageal hematoma is part of a spectrum of esophageal injuries. Vomiting and straining, endoscopic procedures and bleeding disorders are the most common predisposing factors. However, it can also be an unusual complication of anticoagulation and/or thrombolysis therapy. The most common symptoms are retrosternal chest pain, dysphagia and hematemesis. Computed tomography is the modality of choice and treatment is medically conservative with the cessation of Warfarin and thrombolysis use. When anticoagulation and/or thrombolysis therapy is necessary, periodic reassessment for symptoms of intramural esophageal hematoma may be helpful for early identification and management. We described one case of intramural esophageal hematoma possibly resulting from anticoagulation and/or thrombolysis therapy in the setting of pulmonary embolism.

Hematoma esofágico intramural: de la disección a la perforación / Intramural esophageal hematoma: Dissection of the perforation

El hematoma esofágico intramural es una entidad infrecuente, con pocos casos registrados en la literatura. Existen factores de riesgo que favorecen la aparición de esta condición como las náuseas y el vómito. Su presentación clínica más frecuente es la tríada de hematemesis, disfagia y dolor torácico. El tratamiento es conservador en la mayoría de los casos. En este trabajo presentamos nuestra experiencia en 7 casos recolectados durante los últimos 8 años, en los cuales se puede apreciar todo el espectro de la enfermedad desde la disección submucosa hasta la perforación del esófago.

Intramural esophageal hematomas are rare with few cases reported in the literature. Risk factors that affect the incidence of this condition include nausea and vomiting, but its most common clinical presentation is the triad of hematemesis, dysphagia and chest pain. Conservative treatment is best in most cases. We present our experience in 7 cases collected during the last 8 years in which you can see the entire spectrum of the disease from submucosal dissection to perforation of the esophagus.

Hematoma masivo esofágico con compromiso supraglótico: reporte de un caso y revisión de la literatura / Massive esophageal hematoma with supraglottic extension: report of a case and review of the literature

Se presenta el caso de un paciente de 67 años de sexo masculino, hipertenso, diabético y usuario de aspirina en dosis anticoagulante, que consulta en el servicio de urgencia por un cuadro de inicio súbito de dolor retroesternal asociado a disnea severa y estridor. La evaluación mediante nasofibroscopfa muestra una gran masa supraglótica que obstruye el 80 por ciento del lumen, compatible con una masa esofágica. La tomograffa computarizada de tórax muestra una imagen compatible con un hematoma disecante esofágico de gran extensión, desde laringe hasta la unión gastroesofágica. El paciente se maneja en forma conservadora mediante observación, analgesia y alimentación párenteral. Se evalúa en forma periódica con tomograffa computarizada y nasofibroscopfa. Evoluciona con reabsorción progresiva del hematoma y disminución del compromiso laríngeo por lo que es dado de alta a los 10 días. Este caso ejemplifica una rara patología que además tiene una forma atípica de presentación, con obstrucción laríngea.

We present a case of a 67 years old hipertense and diabetic male. The patient refered a sudden onset of chest pain associated with severe dysnea and audible stridor. Nasofibroscopy showed a supraglottic mass that obstructed an estimated 80 percent of normal lumen, suggestive of an esophageal mass. Thorax CT scan revealed an ¡mage of a dissecting esophageal haematoma that compromised most of the esophageal extension, beggining at the laryngeal plane. The patient was managed by conservative means, through observation, analgesia and parenteral nutrition. Close follow up, by CT Scan as well as nasofibroscopy. The patient evolved well, with haematoma reabsorption and decrease of laryngeal obstruction being discharged after 10 days of hospitalization. We report a rare entity that presented in an unusual way.