Spontaneous intramural esophageal hematoma

We report the case of an 80-year-old woman who developed a spontaneous intramural esophageal hematoma and review the available literature. Spontaneous intramural esophageal hematoma (SIOH) is a rare but important condition. Because the cardinal symptom is severe chest pain, the condition is often initially misdiagnosed as an acute cardiac event or aortic dissection. Increased awareness of SIOH may prevent misdiagnosis on the basis of endoscopic and radiological appearances.     

Esophageal laceration with intramural dissection mimics esophageal perforation

Esophageal laceration with intramural dissection is a rare type of injury but without perforation. It is difficult to differentiate from esophageal perforation at presentation time. We report the case of a 46-year-old man who was admitted to our hospital complaining of progressive chest pain, dysphagia, and odynophagia after swallowing a fish bone three days prior to admission. Esophagoscopy revealed a deep longitudinal laceration with pus discharge in the esophagus. Computed tomography of the chest revealed low posterior mediastinal abscess formation. Surgery was performed under the impression of esophageal perforation. The definite diagnosis was esophageal laceration with intramural dissection.     

食管壁内夹层的诊断与治疗——附一例报告及文献复习

目的 探讨食管壁内夹层(intramural esophageal dissection,IED)的可能发病机制、临床表现、诊断方法和治疗预后,以提高IED的诊疗水平.方法 回顾性分析2010年2月上海交通大学附属第一人民医院收治的1例全胸段食管环状壁内夹层、假腔严重感染合并局限性食管破裂患者的临床资料,女,56岁.行...     

Intramural esophageal dissection in a young man with eosinophilic esophagitis

Intramural esophageal dissection is a rare disorder that should be considered in patients presenting with chest pain, dysphagia, and hematemesis. Although most commonly occurring in elderly women with impaired coagulation, esophageal dissection has also been observed in other demographics including in those with eosinophilic esophagitis. In our report, we present the case of a 19-year-old man who was found to have an intramural esophageal dissection in the setting of undiagnosed eosinophilic esophagitis. There have been multiple, proposed management strategies; however, we implemented a nonoperative approach and obtained successful results. Intramural esophageal dissection is an important diagnosis for thoracic surgeons to be aware of as these patients often present as surgical emergencies, but often do not require an acute surgical intervention.     

Intramural pseudodiverticulosis of the esophagus

Two cases of esophageal intramural pseudodiverticulosis are presented. A brief review is made of previously published reports. This entity, first described in 1960, is still rarely diagnosed. Its etiology is still debatable. However, as more cases are published, it becomes more apparent that esophageal intramural pseudodiverticula can be found as part of a distinct syndrome with diffuse intramural pseudodiverticulosis, as originally described by Mendl, or localized in a limited extension of the esophagus as a response to esophageal obstruction.     

Acute dissection of the descending aorta: noncommunicating versus communicating forms

BACKGROUND: Noncommunicating dissecting intramural hematoma is an aortic dissection variant, characterized by absent flow within the false lumen. Noncommunicating dissecting intramural hematoma is thought to be more stable than communicating dissection when beginning in the descending aorta. This study assessed clinical characteristics, anatomic characteristics, and 1-year outcomes in acute descending noncommunicating dissecting intramural hematoma versus communicating dissection. METHODS: Retrospective database review identified patients who underwent magnetic resonance or computed tomography imaging revealing acute descending noncommunicating dissecting intramural hematoma or communicating dissection. Comparisons of clinical and anatomic characteristics and 1-year outcomes were performed. RESULTS: Twenty-four noncommunicating dissecting intramural hematoma and 36 communicating dissection cases were identified. Patients with noncommunicating dissecting intramural hematoma were older (68.5 +/- 8.8 versus 61.8 +/- 11.6 years; p < 0.05). Although noncommunicating dissecting intramural hematoma often showed abdominal aorta extension (50%), the infrarenal level was spared. Communicating dissection characteristically extended beyond the diaphragm (89%), including into the infrarenal aorta (28%). There was no significant difference in rates of adverse clinical events for noncommunicating dissecting intramural hematoma versus communicating dissection (13% versus 30%; 0.10 > p > 0.05). By follow-up imaging (87% of population), aortic deterioration was more frequent in noncommunicating dissecting intramural hematoma versus communicating dissection cases (60% versus 15%; p < 0.005). CONCLUSIONS: Acute descending noncommunicating dissecting intramural hematoma and communicating dissection represent two variants, with differing clinical and anatomic characteristics, but comparable levels of 1-year morbidity.     

Assessment of aortic dissection and hematoma

Aortic dissection and aortic intramural hematoma are highly lethal diseases occurring mostly in patients with arterial hypertension or Marfan syndrome. Transesophageal echocardiography (TEE) is the diagnostic imaging procedure of choice in the unstable patient. Hallmarks of dissection are the presence of an intimal membrane, or flap, dividing a true and a false lumen, entry and reentry tears, periaortic hematoma, pericardial effusion or tamponade, and aortic regurgitation in dissection of the ascending aorta. TEE allows detection of involvement of the ascending aorta, which places the patient in an extremely high-risk group and necessitates urgent operation. The accuracy of TEE is similar to computed tomography and magnetic resonance imaging, with the added benefit of being feasible at the bedside or in the operating room. Precautions have to be taken during TEE to avoid an abrupt rise in blood pressure. Aortic intramural hematoma is often a precursor of classic dissection or accompanies it and can also be diagnosed by TEE, although the diagnosis is frequently difficult.     

Evolution toward dissection of an intramural hematoma of the ascending aorta

Intramural hematoma of the aorta is a condition increasingly observed in clinical practice. Uncertainty exists whether such lesions represent a different pathology or simply the precursors of classic dissecting aneurysm. The patient was a 76-year-old woman with intramural hematoma of the ascending aorta. Clinical course, progression of the lesion to type A aortic dissection, and surgical treatment are described. Although natural history of intramural hematoma of the ascending aorta is not clearly elucidated, the case presented confirms that the evolution toward intimal flap formation is possible and that we cannot foresee the stabilization of these lesions. We stress that intramural hematoma of the ascending aorta has to be managed as an aortic type A dissection and that aggressive treatment is advisable.     

Dissecting leiomyomas of the uterus other than cotyledonoid dissecting leiomyomas: a report of eight cases.

We report eight cases of benign uterine smooth muscle neoplasms with unusual growth patterns and intramural dissection. All the patients in our series were of reproductive age or perimenopausal (range, 36-51 years) and had an enlarged uterus or a pelvic mass, with the exception of one lesion that was found incidentally in a patient treated for uterine prolapse. Three also had abnormal uterine bleeding. On gross examination, the lesions had an unusual appearance and were often lobulated and irregular with indistinct margins. On microscopic examination of all the lesions in this study, a dominant benign smooth muscle tumor was associated with intramural dissection of the myometrium by fascicles of neoplastic smooth muscle. Of the eight cases showing intramural dissection, four were intramural dissecting leiomyomas; three were examples of intravenous leiomyomatosis; and one was a multinodular leiomyoma with hydropic degeneration. We excluded cotyledonoid dissecting leiomyomas from the study. In two of the three cases of intravenous leiomyomatosis, extrauterine extensions in continuity with the intramural components were noted at surgery and on gross examination. Intramural dissection of the myometrium by a benign smooth muscle tumor is one additional possibility to be considered in the differential diagnosis of leiomyosarcoma and low-grade stromal sarcoma.     

Thoracoscopic enucleation of benign tumors of the esophagus under simultaneous flexible esophagoscopy

Background: Benign tumors of the esophagus are very rare, accounting for only 0.1–2% of all esophageal tumors. Conventional treatment consists of thoracotomy adapted to the location of the tumor, followed by enucleation of the lesion. This approach, however, involves major surgery. Minimally invasive surgery represents a viable therapeutic alternative, in particular for benign tumors. Methods: In four patients with a benign tumor of the esophagus, we carried out thoracoscopic enucleation under simultaneous esophagoscopy. Results: Using this combination of endoscopic procedures, the tumors were removed reliably and safely. Two of the lesions were intramural leiomyomas, and two were intramural myxoid cysts. Conclusion: This combination of endoscopic procedures represents a minimally invasive approach with correspondingly minor surgical trauma. Using simultaneous esophagoscopy and transillumination (diaphanoscopy) of the esophageal wall, the safety and accuracy of the dissection is increased, and the risk of mucosal perforation minimized. Received: 10 January 2000/Accepted: 30 March 2000/Online publication: 29 August 2000     

Recurrent type B intramural hematoma progressed into type A acute aortic dissection in a young otherwise healthy woman: are there unknown background factors?

Intramural hematoma is reported with increasing frequency but the recurrence after complete resolution is rarely reported. We herewith describe a case of type B intramural hematoma in an otherwise healthy 39-year-old woman showing unusual clinical course in which acute aortic dissection developed three months after complete resolution of intramural hematoma. The case clearly reminded us of the potential of intramural hematoma for recurrence and progression to frank aortic dissection even after complete resolution.     

A case of intramural oesophageal dissection secondary to nasogastric tube insertion

Intramural oesophageal dissection is a rare disorder, caused by the interposition of a divisive force between the mucosal and muscular layers of the oesophagus, leading to their separation. We present a case of intramural oesophageal dissection, secondary to the accidental iatrogenic intramural insertion of a nasogastric tube. We discuss the aetiologies, presentation, investigation and treatment of intramural oesophageal dissection, and make recommendations on the management of suspected oesophageal perforation with prophylactic nasogastric tube insertion. We also discuss other complications associated with nasogastric tube insertion, and how these may be avoided.     

Clinical study on responses of the upper esophageal sphincter after subtotal esophagectomy for esophageal cancer]

Responses of the upper esophageal sphincter (UES) to distention of the esophageal wall by use of a balloon catheter were measured in 30 patients after subtotal esophagectomy for esophageal cancer and 33 volunteers with unrelated disorders (control group). Patients were divided into extended dissection group and non-extended dissection group according to the width of lymph node dissection, or palsy group and non-palsy group according to recurrent-laryngeal nerve palsy. The resting upper esophageal sphincter pressure (UESP) and the upper esophageal sphincter contraction (UESC) following UES induced by swallowing were measured after esophageal distention. Neither of UESP nor UESC without distention was significantly different among each group. But those of the extended dissection group and palsy group after esophageal distention were significantly lower values than those of control group. These findings suggest that responses of the UES to distention of esophageal wall are decreased, thus protection against aspiration is probably decreased.     

Spontaneous intramural esophageal hematoma

Spontaneous intramural esophageal hematoma is a rare cause of chest pain. Erroneous diagnosis may cause inappropriate management and disaster. We describe one case of spontaneous intramural hematoma that was successfully managed by conservative treatment. Endoscopic and radiographic images are reviewed. The benefit of endoscopic ultrasound is emphasized.     

Esophageal hypermotility associated with intramural pseudodiverticulosis. Primary esophageal disease or epiphenomena?

Esophageal intramural pseudodiverticulosis is a very rare disease of unclear etiology. The clinical picture is characterized by progressive dysphagia. Because of its frequent association with alcohol abuse and subsequent weight loss, it must be differentiated reliably from esophageal carcinoma. The diagnosis is established by the characteristic detection of multiple intramural contrast accumulations in the barium esophagogram. Additional endoscopic and endosonographic confirmation and histological examination are required to exclude a malignant tumor. Moreover, associated diseases are almost always present and should also be diagnosed by pH-metry, cytology, and esophageal manometry. Good and long-lasting therapeutic success can be achieved by bouginage of the stenosis with concomitant treatment of the associated esophageal diseases. Based on two case reports of patients with this disease, we discuss the unusual association with esophageal hypermotility as well as the symptoms, clinical course, therapy, and pathogenesis of the disease.     

Endovascular treatment of thoracic aortic dissection and its variants

The acute aortic syndrome (AAS) is described. Its pathophysiology is discussed for each of the three entities (penetrating aortic ulcer, intramural hematoma and aortic dissection). The natural history of these three pathologies is reviewed. Diagnostic features and investigation imaging techniques are summarized. The technique of stentgraft-placement is described in detail. The authors report their clinical experience with 127 patients, presenting acute type B aortic dissection or its variants, and treated with an endovascular stent-graft-device. These results are in part compared with a group of control patients with acute type B dissection, submitted to medical non-invasive therapy.     

Intramural hematoma of the esophagus: a complication of carbon tetrachloride intoxication with acute renal failure.

Following a period of prolonged severe vomiting, an intramural esophageal hematoma could be demonstrated by endoscopy and by X-ray in a 21 year old patient with hepatic and renal failure after exposure to carbon tetrachloride. The hematoma resolved spontaneously. The intramural hematoma is thought to have developed from a microdissection of the esophageal wall in the presence of a hemorrhagic diathesis.     

Endovascular Treatment of Thoracic Aortic Dissection and its Variants

The acute aortic syndrome (AAS) is described. Its pathophysiology is discussed for each of the three entities (penetrating aortic ulcer, intramural hematoma and aortic dissection). The natural history of these three pathologies is reviewed. Diagnostic features and investigation imaging techniques are summerized. The technique of stentgraft-placement is described in detail. The authors report their clinical experience with 127 patients, presenting acute type B aortic dissection or its variants, and treated with an endovascular stent-graft-device. These results are in part compared with a group of control patients with acute type B dissection, submitted to medical non-invasive therapy.     

Extended transmediastinal dissection: an alternative to gastroplasty for short esophagus

HYPOTHESIS: The significance of short esophagus and its impact on failure after laparoscopic Nissen fundoplication are unknown. Although patients with severe esophageal shortening that requires Collis gastroplasty comprise a small percentage of patients undergoing fundoplication, we hypothesize that patients with moderate esophageal shortening requiring extended mediastinal dissection make up a larger subgroup and that extended laparoscopic mediastinal dissection is a good treatment strategy for such patients. DESIGN AND SETTING: Retrospective comparative analysis in an academic and private practice-based tertiary referral center. PATIENTS: A total of 205 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernias over 4 years. Outcomes in patients requiring either a type I (<5 cm) or type II (>5 cm) mediastinal dissection were compared. INTERVENTIONS: Laparoscopic Nissen fundoplication with or without extended mediastinal dissection and esophageal physiology testing. MAIN OUTCOME MEASURES: Symptom assessments, operative reports, and outcomes were prospectively recorded on standardized data sheets. Postoperative symptom assessment and esophageal physiology testing were performed. RESULTS: A total of 133 (65%) of the 205 patients underwent type I dissection, and 72 (35%) of the 205 patients underwent type II dissection. Failure occurred in 15 (11%) of 133 patients and 6 (10%) of 72 patients, respectively. The presence of a large hiatal or paraesophageal hernia predicted the need for type II dissection. CONCLUSIONS: No difference was seen in failure rates between patients who required a type II dissection and those who did not. This finding suggests that aggressive application of laparoscopic transmediastinal dissection to obtain adequate esophageal length may reduce fundoplication failure in patients with esophageal shortening and provide a success rate similar to that of patients with normal esophageal length. More liberal application of Collis gastroplasty in these patients is not warranted.     

Clinicopathological study on the intramural metastasis of the esophageal cancer

Intramural metastasis and microscopical lymphatic permeation (distant-ly) distant more than 5mm from primary lesion were evaluated clinicopathologically in 207 patients with esophageal cancer, to reveal intramural lymphatic metastasis in esophageal cancer. Thirty-one lesions of intramural metastasis in 21 patients (10%) and 85 distant-ly lesions in 19 patients (9%) were observed. Both lesions existed mainly in lpm or sm layer and located within 5cm from primary lesion. As a direction of metastasis, intramural metastasis existed almost equivalently oral and anal from primary lesion, but distant-ly existed slightly more frequently in anal direction. When intramural metastatic lesion was recognized oral from primary lesion, lymph node involvement of the upper mediastinum was present in 67% of cases. On the other hand, intramural metastasis was seen anal from primary lesion and lymph node involvement of upper paragastric region was present in 100% of cases. Patients with intramural metastasis showed poor prognosis of one year of 50% survival period.