Esophageal Hematoma

Etiology

The proposed mechanism involves a rapid alteration in intrathoracic and intraesophageal pressures triggered by events such as vomiting, retching, and coughing, leading to the formation of an intramural hematoma that may rupture into the esophageal lumen. Additional risk factors include the use of anticoagulant or antiplatelet medications and an underlying coagulopathy. In certain cases, esophageal hematomas can occur spontaneously without an identifiable cause.[4][5] Secondary causes of esophageal hematomas include:

• Traumatic ingestion of foreign bodies
• Valsalva maneuver
  • Protracted coughing,[6] sneezing, or heavy lifting
  • Severe vomiting [6]
  • Hurried swallowing of a large, bulky bolus
• Nasogastric tube insertion
• Endotracheal intubation [7]
• Upper gastrointestinal tract endoscopy procedures, including esophagogastroduodenoscopy, esophageal forceps biopsies,[8] endoscopic retrograde cholangiopancreatography,[7] and transesophageal echocardiography [7]

Epidemiology

Esophageal traumatic injuries, including traumatic penetration and perforation, are rare and unpredictable, making the incidence and prevalence of esophageal hematomas difficult to estimate.[9] Most cases are reported in case reports. Results from a large case series showed a bimodal age distribution of esophageal hematomas, with peaks at ages 45 and 75.[10] The younger mode is usually associated with vomiting or trauma, whereas the latter mode appears to be related to either a coagulopathy or the use of anticoagulant or antiplatelet medications.

Esophageal hematomas are approximately twice as common in women as in men for reasons not yet understood. Patients with underlying coagulopathic disorders, such as hemophilia, or those taking antiplatelet or anticoagulant medications, are at a higher risk of developing both spontaneous and secondary esophageal hematomas.[11] Although esophageal hematoma is rare, its recognition is increasing due to the widespread availability of modern endoscopic and radiologic facilities.[12][13]

Pathophysiology

In patients with normal blood clotting, retching or vomiting can lead to a submucosal hematoma, typically in the lower esophagus. Hematoma formation suggests that vomiting-induced pressure can damage the mucosa and submucosal vessels. In one reported case, the esophageal submucosal hematoma was located on the right anterior wall of the distal esophagus, an area prone to increased intra-abdominal pressure. Initially, the hematoma formed in the lower esophagus, likely due to a mucosal laceration, leading to bleeding and local vascular collapse. Bleeding from ruptured submucosal vessels likely extended into the upper esophagus, resulting in a widespread esophageal submucosal hematoma.[14]

A sudden pressure change in the esophagus and an underlying bleeding tendency have been proposed as mechanisms of a spontaneous esophageal hematoma. Secondary esophageal hematomas are thought to result from an acute injury with mechanisms similar to those of a Mallory-Weiss tear and Boerhaave syndrome, with the intramural hematoma representing an intermediate stage. The proposed initiating cause of this condition is sudden bleeding between the mucosa and muscularis propria of the esophageal wall, sometimes involving a long segment of the esophagus. Progressive submucosal dissection from bleeding leads to symptoms ranging from severe chest or upper abdominal pain to signs of esophageal luminal obstruction. Later, a breach of the mucosa containing the hematoma can occur, presenting as hematemesis.[10] 

History and Physical

An esophageal hematoma usually presents with sudden-onset chest or retrosternal pain. At least half of patients present with at least 2 symptoms from the classic triads,[15] including retrosternal chest pain (66% to 84%), dysphagia or odynophagia (70%), and hematemesis (26%).[16] When taking the patient’s history, clinicians should inquire about any bleeding diathesis or use of anticoagulants.

A history of violent retching, vomiting, or esophageal instrumentation may also be present, and the patient may experience upper abdominal pain rather than chest pain. Rarely, a history of foreign body ingestion may be present. The presence of dysphagia or odynophagia makes significant cardiac causes of retrosternal pain less likely.[16] Physical examination typically reveals only nonspecific findings, such as tachycardia, hypotension, and pallor.

Evaluation

Multiple modalities have been used to diagnose this condition.[17] The preferred primary investigation is a contrast computed tomography (CT) scan of the chest (with or without the abdomen).[6] A contrast-enhanced CT scan delineates the anatomical relationship between the esophagus, aorta, and mediastinal structures.

The study often demonstrates a thickened esophageal wall with a smooth filling defect within the esophageal lumen. Luminal compression or, in cases of large hematomas, luminal obliteration may be demonstrated. Imaging with oral contrast should be performed when transmural perforation is suspected. Extraluminal extravasation of oral contrast is diagnostic and can localize the mucosal rent. An intraesophageal mass or filling defect may be visualized, sometimes resembling a double-barreled or dual lumen.

MRI can show a mass of intermediate density on T1- and T2-weighted images, distinguishing an esophageal hematoma from other mediastinal pathologies and demonstrating soft tissue planes around the aorta. Endoscopic modalities, such as esophagogastroduodenoscopy and endoscopic ultrasonography, can help diagnose an esophageal hematoma. Endoscopy should be postponed until the integrity of the esophageal wall has been established. Endoscopy reveals a bluish prominence with or without a mucosal tear. Endoscopic ultrasonography is superior to conventional endoscopy because it can demonstrate submucosal lesions and evaluate adjacent structures.

An electrocardiogram, chest radiograph, and cardiac markers are useful in excluding cardiopulmonary diseases that might be mistaken for an esophageal hematoma. The presence of a pneumothorax, pneumomediastinum, or pleural effusion should raise a strong suspicion of a transmural injury to the esophagus and an intramural hematoma. Grading of the degree of luminal involvement by the hematoma is as follows:

• Stage I: Isolated hematoma
• Stage II: Hematoma surrounded by tissue edema
• Stage III: Hematoma causing compression of the esophageal lumen
• Stage IV: Complete obliteration of the esophageal lumen by the hematoma [15]

Treatment / Management

Treatment for esophageal hematomas is usually conservative. Initial treatment involves withholding oral intake, administering intravenous fluids and a proton pump inhibitor, and correcting any associated coagulopathy. Serial CT scans or contrast swallow studies are needed to monitor clinical progress and hematoma resolution. The patient is gradually allowed oral feeding as symptoms improve. In most cases, medical and conservative treatment results in complete patient recovery. This method is suitable for cases in which the muscle layer is unaffected. The hematoma can be absorbed within 1 to 3 weeks, with complete resolution in 2 to 4 weeks.[18] (see Image. Progression and Healing Stages of an Esophageal Hematoma).(A1)

Recurrent bleeding or increased dysphagia should raise suspicion for hematoma leakage into the esophageal lumen or obstruction by an expanding unruptured hematoma, respectively. These situations should be treated as acute emergencies, with hemodynamic resuscitation and airway protection.[5][19] An endoscopic needle knife can be used to incise an obstructing hematoma, allowing drainage.[20] Therapeutic angiography may become necessary in cases of recurrent massive hematemesis to stop bleeding and hematoma expansion via transarterial embolization.[18] A thoracoscopic or open surgical procedure is rarely required and is usually performed only as an emergency in cases of full-thickness perforation.[21](A1)

Differential Diagnosis

Other esophageal etiologies include the following:

• Mallory-Weiss syndrome, a distal esophageal or gastric cardia mucosal tear
• Boerhaave syndrome a transmural esophageal perforation
• Aortoesophageal fistula
• Esophageal variceal rupture
• Esophageal cancer

An esophageal hematoma can be considered an intermediate stage between Mallory-Weiss syndrome and Boerhaave syndrome. Chest radiography may reveal pneumomediastinum, pneumothorax, or pleural effusion in cases of Boerhaave syndrome.

Acute retrosternal chest pain has a cardiopulmonary differential diagnosis, including the following:

• Myocardial infarction
• Aortic dissection
• Pulmonary embolism

Hematemesis, dysphagia, or odynophagia in patients with an esophageal hematoma can help differentiate this condition from other critical conditions when used alongside other diagnostic modalities.[22]

Prognosis

Esophageal hematomas have a generally favorable prognosis when managed promptly and appropriately. Most patients fully recover with conservative treatment, including rest, pain control, and dietary modifications. Patients typically experience significant symptom relief within days to weeks, and the hematoma usually resolves completely within a few weeks. However, clinicians should monitor for signs of deterioration, especially in patients with underlying risk factors or comorbidities. Full-thickness perforation is associated with higher morbidity and mortality.

Complications

Although rare, complications of an esophageal hematoma can be severe and require prompt attention.

The most common complications include:

• Intraluminal bleeding secondary to rupture of the hematoma into the esophageal lumen
• Expansion of the hematoma, causing esophageal luminal obstruction (signaled by progressive dysphagia)
• The most significant complication is esophageal perforation, which can lead to mediastinitis and sepsis and necessitate surgical intervention

Less frequent potential complications include:

• Secondary infection of the hematoma
• Stricture formation due to scar tissue
• Rebleeding, especially in patients with underlying coagulopathies or those taking anticoagulant or antiplatelet therapy
• Aspiration of blood or necrotic tissue into the lungs [23]