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.     

Mechanical tracheal obstruction due to an intramural esophageal hematoma following endoscopic variceal sclerotherapy.

Endoscopic injection sclerotherapy is widely used as treatment for bleeding esophageal varices. Esophageal intramural hematoma is a rare complication following endoscopic injection sclerotherapy. Patients present with pain and dysphagia due to esophageal obstruction. We present the first reported case of respiratory failure resulting from an intramural hematoma causing posterior tracheobronchial compression. Although patients with alcoholic cirrhosis and bleeding varices requiring respiratory support generally have a poor prognosis this may be an occasion when ventilatory support may be expected to be easily withdrawn after hematoma resolution.     

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.     

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.     

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.     

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.     

Laparoscopic drainage of a post-traumatic intramural duodenal hematoma in a child

Duodenal intramural hematoma owing to blunt abdominal trauma is a relatively rare condition and is normally managed non-operatively. In this paper, we present the case of an 11-year-old boy with a post-traumatic duodenal hematoma, who after failing conservative management, underwent laparoscopic drainage. A four-port approach in a similar position to the laparoscopic cholecystectomy was used. After disentangling the inflammatory mass, the duodenal serosa was opened by simple hook diathermy and the hematoma evacuated. The child recovered uneventfully and was discharged home 48 hours later. To our knowledge, this is the first time that this condition has been successfully treated laparoscopically.     

How to mimic a type A intramural hematoma: A case of IgG4-related aortitis associated with cerebral hemorrhage

IgG4-related aortitis is an inflammatory condition of the aorta, characterized by aortic wall thickening and periaortic soft-tissue involvement. Therefore, this condition can mimic an aortic intramural hematoma (IMH), due to similar radiological findings. We hereby report the case of an IgG4-related aortitis misdiagnosed as an IMH, associated with cerebral hemorrhage, possibly due to cerebral vascular system involvement.     

Intramural esophageal hamartoma. An unusual cause of progressive stricture in a child.

The unusual occurrence of an intramural hamartoma mimicking a peptic esophageal stricture in a child is presented. Early operative intervention is indicated to diagnose the condition and to avoid certain morbidity or death. The remarkable embryologic feature of this report is the presence of annular cartilage at the site of the esophageal stricture. Conservative resection of the involved esophagus and primary anastomosis is the treatment of choice.     

Management of patients with intramural hematoma involving the ascending aorta

OBJECTIVE: Although intramural hematoma of the aorta is considered a unique pathologic entity, the management of intramural hematoma involving the ascending aorta (type A) has not been well established. The purpose of this study was to establish the optimal mode of management of type A intramural hematoma. METHODS: We treated patients with type A intramural hematoma as follows. Early operation was carried out only for patients with cardiac tamponade, impending rupture, or rupture. Other patients were treated medically, but patients with progression of intramural hematoma during medical follow-up had their treatment converted to surgery. From February 1992 to March 2001, a total of 33 patients with type A intramural hematoma were treated as described here. Patients were divided according to initial treatment into an early surgery group (n = 9) and a medical treatment group (n = 24). Clinical profiles and in-hospital and long-term survival rates were compared between the groups. RESULTS: Compared with the early surgery group, the medical treatment group was younger (64.2 +/- 7.0 years vs 71.7 +/- 8.5 years, P =.0319) and had a greater number of involved segments (3.6 +/- 0.6 vs 3.0 +/- 0.9, P =.0395). Eight patients in the medical treatment group were switched to surgery during follow-up because of progression of intramural hematoma. In-hospital mortality rates in the early surgery and medical groups were 11% and 5% (P =.477), respectively. Cumulative 1- and 2-year survivals were 89% and 89%, respectively, in the early surgery group, and 92% and 81%, respectively, in the medical group (P =.49). CONCLUSION: We concluded that about 70% of type A intramural hematomas could be managed expectantly, and more than 50% could be treated medically alone.     

Dysphagia soon after off-pump coronary surgery: the single suture technique.

We report a case of a 76-year-old man complaining of dysphagia for solid food associated with a weight loss following an off-pump double vessel coronary artery revascularization. Multislice spiral computed tomography showed a 6 cm x 2.5 cm solid formation next to the posterior wall of the left atrium, adjacent to the pericardium and the right anterolateral side of the esophagus. The mass was confirmed to be an intramural esophageal hematoma by endoscopic ultrasound-guided fine-needle aspiration cytology. Injury to esophagus during the placement of deep pericardial sutures and postoperative infusion of heparin are claimed to be causes of this complication.     

Traumatic oesophageal perforation due to haematoma

INTRODUCTION

Traumatic oesophageal perforation is a rare, life-threatening emergency that requires early recognition and prompt surgical management.

PRESENTATION OF CASE

We present an unusual case of a patient on warfarin treatment developed an intramural oesophageal haematoma following blunt thoracic trauma leading to perforation on the 18th day.

DISCUSSION

In treatment of oesophageal haematoma in patients on vitamin-K antagonists, strict control of the International Normalized Ratio (INR) is essential along with total parenteral nutrition therapy and refrainment through nasogastric tubes. Three explanations postulated to be the cause for late perforation which might be due to esophageal wall ischemia from pressure built up between the hematoma, azygos vein and the lower part of thoracic trachea; or could be an immediate rupture walled-off until the patient became symptomatic; or the intramural hematoma gradually lysed and causing late perforation.

CONCLUSION

Although extremely rare, an oesophageal haematoma and late complications must be considered in patients on anti-coagulant therapy following blunt thoracic trauma and complaining only of chest pain.     

Spontaneous intramural left atrial hematoma associated with systemic amyloidosis

Spontaneous intramural left atrial hematoma is very rare. We describe a case of spontaneous intramural left atrial hematoma that had to be semiurgently resected. Postoperatively, the patient was diagnosed as having systemic immunocyte-derived (AL) amyloidosis, because of rare manifestations of fatal bleeding. Though spontaneous intramural left atrial hematoma is one of the severe complications of systemic AL amyloidosis, we believe that amyloid deposits caused fragility of the left atrial wall.     

A belly of blood: A case report describing surgical intervention in a gastric intramural haematoma precipitated by therapeutic endoscopy in an anticoagulated patient

Gastric intramural hematoma, “intramural dissection” or “false aneurysm”, is a rare and dangerous condition which may be more broadly classified as a spectrum of acute gastric mucosal injury. It is postulated that disruption of the mucosa and blood vessels within the submucosal layer results in dissection of the muscularis propria from the mucosa, with eventual clot formation. While a majority of cases resolve with conservative management, we describe a successfully managed case requiring surgical intervention. Progression of the haematoma was documented both endoscopically and surgically in an elderly anticoagulated patient who suffered a complication of therapeutic endoscopic intervention. A review of the literature is presented.     

Intramural hematoma of the thoracic aorta in octogenarians: is non operation justified?

OBJECTIVE: The prognostic factors and treatment options for thoracic aortic intramural hematoma are controversial. The purpose of this study was to determine the most suitable treatment of this condition in very elderly patients. METHODS: In a review of the world literature, eight octogenarians with thoracic aortic intramural hematoma were found; to these the three cases reported here must be added. The descending thoracic aorta was involved in eight cases and the ascending/arch in three. RESULTS: In spite of patients' poor general conditions, the medical treatment group showed survival rates of 85.7% (descending) and 66.6% (ascending/arch), respectively. CONCLUSION: Extensive atherosclerotic changes of the aortic wall in the elderly, combined with control of hypertension, may probably prevent thoracic aortic intramural hematoma from progressing to dissection, with a favourable outcome. An earlier and more accurate preoperative diagnosis by modern diagnostic techniques, including spiral computed tomography (CT), as were performed in our own patients, will allow optimal treatment and increased patient survival.     

Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations

Clinically, penetrating atheromatous ulceration of the aortic wall may be confused with either symptomatic thoracic aneurysm or classic spontaneous aortic dissection. Aortography and computed tomographic (CT) scanning of the thoracic aorta provide specific diagnostic information which permits one to distinguish this lesion from atherosclerotic aneurysm and classic dissection. Hallmarks of findings on aortography and CT scan include the presence of the ulcer and an intramural hematoma. Since the findings may be disarmingly subtle, the potentially progressive and serious nature of this condition may remain unappreciated. Recognition of the penetrating atheromatous ulcer and distinguishing it from aortic dissection arising just distal to the origin of the left subclavian artery is mandatory. Resection of only a conservative segment of the proximal descending aorta suffices for classic dissection in the upper descending thoracic aorta, but the penetrating aortic ulcer requires graft replacement in the area of the ulcer and intramural hematoma.     

Type A intramural hematoma presenting with acute right heart failure caused by compression of the main pulmonary artery: a case report

Pulmonary artery obstruction is a rare complication of intramural hematoma of the ascending aorta. There were few reported cases presenting with right heart failure due to compression of the pulmonary trunk by intramural hematoma of the aorta.     

Delayed duodenal intramural hematoma with obstruction

An intramural duodenal hematoma with duodenal obstruction is usually a complication of blunt abdominal trauma, endoscopic biopsy, or peptic ulcer disease. Possible management strategies include conservative treatment, surgical evacuation, and percutaneous or endoscopic drainage. We report on a 40-year-old man with a remote history of trauma who presented with vomiting for 3 days. At surgery, he was found to have an intramural duodenal hematoma causing obstruction.     

Penetrating atheromatous ulcers of the aorta

THORACIC PAINFUL SYNDROME: Penetrating atherosclerotic aortic ulcers represent a condition in which an atherosclerotic plaque ulcerates and disrupts the internal elastic lamina, allowing intramural hematoma formation into the aortic media. Recently individualized as an entity from all vascular thoracic painful syndromes, they affect preponderantly the elderly patients with a medical hypertensive and atherosclerotic history and with multiple cardiovascular risk factors. The descending thoracic aorta is most frequently involved. IMAGING: Computed tomography scanning and magnetic resonance imaging tend to replace aortography in providing an accurate diagnosis of the ulceration and of its parietal extent. Moreover, they allow the discrimination with aortic dissection or with intramural hematoma without intimal rupture which outcome and treatment should differ. RISKS: In the absence of complication, progressive aneurysmal dilatation at the level of the ulcer is a rule. Pseudoaneurysms formation, embolization, and acute transmural aortic rupture can however occur and may justify, in selected cases, a preventive or curative surgical treatment. STENT-GRAFTING: Endovascular stent-grafting techniques may appear as a safe and effective less invasive choice in high-risk patients with suitable anatomical conditions.     

Clinical features and long-term outcome of type A and type B intramural hematoma of the aorta

OBJECTIVE: Most previous reports on intramural hematoma of the aorta have focused on the initial episode. The purpose of this study was to clarify the long-term outcome of intramural hematoma of the aorta. METHODS: Ninety-four cases of intramural hematoma of the aorta (41 type A and 53 type B) were reviewed. There were 69 male and 25 female patients, and their mean age was 66.7 +/- 8.7 years (range, 46-88 years). RESULTS: Eleven (27%) of the patients with type A hematoma and 1 (2%) of the patients with type B hematoma underwent early surgical intervention. Others were treated medically, and the overall hospital mortality was 7% for patients with type versus 2% for patients with type B intramural hematomas of the aorta (P =.315). Twenty-three patients, 9 (22%) with type A and 14 (26%) with type B intramural hematomas of the aorta, underwent late surgical intervention during the follow-up period, and there were no hospital deaths. A total of 23 patients died during the follow-up period, including 6 of intramural hematoma of the aorta-related deaths (3 in the type A group and 3 in the type B group). The estimated freedom from intramural hematoma of the aorta-related events at 1 and 5 years was 70% +/- 8% and 54% +/- 11% for the type A group versus 73% +/- 6% and 58% +/- 8% for the type B group, respectively (P =.972). After excluding the nonintramural hematoma of the aorta-related deaths, the survival rates at 5 and 10 years were 80% +/- 9% and 80% +/- 9% for the type A group and 91% +/- 8% and 81% +/- 11% for the type B group (P =.211). CONCLUSIONS: Intramural hematoma of the aorta-related events occur equally in both types of intramural hematoma of the aorta. We recommend close follow-up for at least 5 years because most intramural hematoma of the aorta-related events occur during this period.