oesophageal apoplexy

8/7/2019 oesophageal apoplexy

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yAn unusual case Of chest pain

M RasoolAljabiri


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y Mrs Smith a 77 - year old Granny

y Presented to the (A&E) department withy Acute onset central chest radiating to the back,

notrelieved with GTN in A&E

y Mild SOB

y Palpitations

y PMHx: HTN, Hypercholesterolemia and DM type 2.Her medications comprised Simvastatin 40mg,

Atenolol 50mg, Bendrofluazide 25mg, Irbesartan75mg and Aspirin 75mg.


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y Chestdiscomforthad been associated with retching,butno vomiting.

yOn examinationy

she appeared in pain pointing to the middleofherchest

y Her vital signs were;

y PR 71 beats/minute,

y

BP 193/83 (no postural drop),y RR 22 breaths/minute

y O2 sats 98% on RA, temperature 37.6oC and BMs14.3 mMol/l.


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CVS-Warm peripheriesJVP NApexnon displacedESM

RespiratoryChestclear

AbdoSoftnon tender

NilepigastrictendernessBS normalDRE soft formed stool


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What would you like to see


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ECG


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CXR


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y Normal Urea and electrolytes

yA mild normocytic anaemia with

haemoglobin of11g/dl wasidentified

yCRP 16 and WCC 12.5yClotting Normal


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Summary 1y 77 Granny

yAcute onset Chest pain

y SOBy Palpitation

y ? Retching prior

y CXR and ECG

y Bloods mildly microcytic anaemia with raised CRP 16and WCC 12.5


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What is the likely diagnosis and what should

her initial management be?

y

y 1) Myocardial ischaemia: aspirin,clexane and clopidogrel whilstawaiting for a Troponin T.

y 2) Pulmonary embolism: clexane at treatment dose whilst awaiting aCT pulmonary angiogram.

y 3) Oesophageal spasm: barium swallow and relief of precipitatingfactor.

y 4) Dissecting aortic aneurysm: urgent CT chest

y She was initially managed by A&E staff according to the AcuteCoronary Syndrome (ACS) in View of her history of acute CP, HTN,Hypercholesteraemia ; ASA, Clopidogrel however clexane was withheldpending a CT as the CXR was suspicious of a dilated mediastinum


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y Twohours later shehad experienced transient

difficulty in swallowing food. She mentioned to theReg thats whathappened when she atethe apple.

y Whilst in A&E (waiting for 3 hrs for an acute bed) shevomited 50ml of fresh blood. (one episode)

y She remained stable after theepisode ofhaematemesis.

y The patient was managed conservatively with

intravenous fluids, PPI and NBM. Fluid resuscitationwas commenced

y ASA&Clopidogrel were stopped.


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yA 12 Hour Troponin was negative

y No change in her vital signs, no postural drop.

y Repeat Urea slightly raised 9


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Summary 2y 77 Granny

yAcute onset Chest pain

y Strated on Clexane,ASA,Clopidiogrely SOB

y Dysphagia

yVomiting (haematamesis) X 1, ? Retching prior

y CXR and ECG

y Stopped clexane and clopidogrel


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What are your differentials now?

1) all ry eiss tear: r e t astr scopy it a vie toe oscopic treat e t.

2) esopha eal tear ( oerhaave's sy rome):

astrograffi s allowa chest.

3) lee secondary to antiplatelets.

) issecting aortic ane rysm: rgent chest.


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ow e c ever gas roen ero og s

comes in,so guess what does he

request?ySuggests an OGD


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Endoscopy was performed

Endoscopy imagesWithin theposterior oesophagus tongue like tissue was seen at 17cmfrom the incisors.


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yAs a good registrar , I asked the nurses to call theconsultant to have a look for advice.(on WR)

y So the consultant moved the idiot registrar a side.

y Ofcourse he didnt know what was going on either.

y Biopsies were taken

yA second opinion was sorted within 3 hours of theendoscopy from a senior consultant

y experience played a crucial role here

y thought this is oesophageal Apoplexy


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y The differential diagnosis

y Benign ulcer with adherent clot,.

y An underlying malignant ulcer,y Transported organised clot within the oesophagus or

oesophageal haematoma/ Apoplexy, secondary to anunderlying tear.


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yAfter endoscopy; retrospective hx from the patient,suggested that 24hr prior to her admission while she

was eating an apple she choked and developed somedifficulty in swallowing that she did not take anynotice off.

y

Hence a water soluble swallow arranged to excludedoesophageal perforation.

y Then A CT scan was arranged


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Water soluble swallow


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There is asymmetric thickening of the oesophageal wall at the level of the left atrium which has an

elliptical appearance and which could represent a sub-mucosal collection (abscess or haematoma)

or tumour.


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Oesophageal Apoplexy/ Haematoma

Spontaneous oesophageal haematomas are a rare consequence of either spontaneousoesophageal injury or high oesophageal pressure. An underlying disorder of haemostasismay be present.[1] A limited number of cases of giant intramuraloesophageal haematoma have previously been described. Bonnette P, Lansac E, Fritsch J: [Intramuralhematoma of the esophagus: a rare diagnosis]. Rev Mal Respir 1999 Dec; 16(6): 1147-50.

The combination ofchest pain,

dysphagiahaematemesis and odynophagiain association with disorders of haemostasis, fragility of the mucosa, ortrauma of the oesophagus, should evoke the diagnosis.[2-5]

Meulman N, Evans J, Watson A: Spontaneous intramural haematoma of the

oesophagus: a report of three cases and review of the literature. Aust N Z J Surg

1994 Mar; 64(3): 190-3 ,3. Freeman AH, Dickinson RJ: Spontaneous intramural oesophageal haematoma. Clin Radiol 1988 Nov; 39(6): 628-34

Hiller N, Zagal I, Hadas-Halpern I: Spontaneous intramural hematoma of the esophagus. Am J Gastroenterol 1999 Aug; 94(8): 2282-4

Yuen EH, Yang WT, Lam WW: Spontaneous intramural haematoma of the oesophagus: CT andMRI appearances. Australas Radiol May;42(2):139-42 1998

Radiology (thoracic CT scan, barium or water soluble swallow) and endoscopyenable confirmation of the diagnosis, permitting conservative treatment and simplespontaneous resolution as in our case (illustration 1). [6-7] thehaemorrhageusuallyoccurs within submucosal/ intramural tissues [6]. Sanaka, Masaki M.D., Ph.D.et alSpontaneous Intramural

Haematoma Localized in the Proximal Esophagus: Truly "S

pontaneous"Journal of Clinical Gastroenterology. 27(3) 265-266, October 1998.


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Oesophageal haematoma may occur at various sites of the oesophagus.

The mechanism producing the haematoma may determine the site. Forexample;

-A haematoma from vomiting would be in the region of the oesophago-

gastric junction.

- A haematoma from acaustic substance might be at points of narrowing.


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Aetiology

1. Dr ugs: coagulation disorders ortreatment with various drugs suchas low-dose aspirin.

2. Miscellaneous:A- Extra luminal causes;i. Chest traumaii. Cardioversion and subsequent anticoagulation.

B- Intra Luminal;i. Foreign body ingestionii. Food-induced injury(as in this case), as a result of abrasive traumaiii Toxin ingestioniv. Pill induced oesophageal injury

v. Instrumentation (e.g. endoscopy with variceal sclerotherapy or biopsy,transoesophageal echocardiogram).

vi. Oesophageal diverticulum, arterio-venous malformation.vii Aorto-oesophageal fistula.[8] Maher MM, Murphy J, Dervan P: Aorto-oesophageal fistula presenting as a

submucosal oesophageal haematoma. Br J Radiol 1998 Sep; 71(849): 972-4

viii.Coughing, retching and prolonged vomiting

C- Oesophageal Bar

otr

aumas.


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Stages ofhaematoma [9]

I) Haematoma without surrounding tissueoedema, these patients arenormally asymptomatic.

II) Haematoma with surrounding tissueoedema, e.g. after an oesophagealbiopsy.

III) Haematoma with oedema plus compression ofthe oesophageal lumen -oedema and separation of the surfacemucosal layer partiallyobliterates the lumen.

IV) Completeobliteration ofthe lumen withhaematoma, oedema andorganized clot formation resulting in absolutedysphagia.


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Endoscopic appearance of the oesophagus at 17cm from the incisors eight weeks post

discharge: complete mucosal healing with no evidence of tumour.


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The diagnosis of Oesophageal Apoplexy / Haemorrhage is rare; therefore a clear

management approach has not yet been established.

For spontaneous intramural haematoma, conservative therapy leads to an excellentprognosis.

Oesophageal haematomas usually resolve within 10-14 days.[1]

Once the diagnosis is suspected the patient should be made NBM and the upper GI

surgeons informed.

Acid suppression should be considered to reduce the risk of oesophageal ulceration and

correction of any coagulation abnormalities is indicated.

Investigations, as discussed above, should be undertaken to confirm the diagnosis.

Once the patient is stabilised (which may take 4-6 days) a soft diet may be started.

Endoscopic sclerotherapy, used previously when extensive oesophageal haematoma was

present, has the associated risk of rupture of the intramural haematoma.[9-10] and thus

is not routinely indicated.

Massive ongoing haematemesis, reported in an earlier literature review as

occurring in 19% of 31 patients presenting with oesophageal haematoma, is the only

indication for surgery. [10]

Discussions


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References:

1. Bonnette P, Lansac E, Fritsch J: [Intramural hematoma of the esophagus: a rare

diagnosis]. Rev Mal Respir 1999 Dec; 16(6): 1147-50. 2. Meulman N, Evans J, Watson A: S pontaneous intramural haematoma of theoesophagus: a report of three cases and review of the literature. Aust N Z JSurg

1994 Mar; 64(3): 190-3 3. Freeman AH, Dickinson RJ: S pontaneous intramural oesophageal haematoma.Clin Radiol 1988 Nov; 39(6): 628-344. Hiller N, Zagal I, Hadas-Halpern I: S pontaneous intramural hematoma of theesophagus. Am J Gastroenterol 1999 Aug; 94(8): 2282-4

5. Yuen EH, Yang WT, Lam WW: S pontaneous intramural haematoma of theoesophagus: CT andMRI appearances. Australas Radiol May;42(2):139-42 19986. Sanaka, Masaki M.D., Ph.D.et alSpontaneous Intramural Haematoma Localizedin the Proximal Esophagus: Truly "Spontaneous"Journal of ClinicalGastroenterology. 27(3) 265-266, October 1998.7. Cullen S N,Chapman RW: Dissecting intramural haematoma of the oesophagusexacerbated by heparin therapy. QJM 1999 Feb; 92(2): 123-4.8. Maher MM, Murphy J, Dervan P: Aorto-oesophageal fistula presenting as asubmucosal oesophageal haematoma. Br J Radiol 1998 Sep; 71(849): 972-4.9. Ouatu-Lascar R, Bharadhwaj G, Triadafilopoulos G.Endoscopic appearance ofesophageal World J Gastroenterol, 2000;6(2):307-309

10. Skillington PD, Matar KS , Gardner MA: Intramural haematoma of theoesophagus complicated by perforation. Aust N Z JSurg 1989 May; 59(5): 430-2


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oesophageal apoplexy

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