oesophageal perforations are associated with high morbidity and mortality , predominantly as a result of a mediastinal leakage frequently leading to septic shock . we report a patient on warfarin therapy presenting an intramural , intrathoracic eosophageal haematoma prior to oesophagus perforation ; a condition that to our knowledge is not previously reported . in our patient , an initial conservative approach was used in managing the haematoma and once perforated prompt surgical intervention was initated . a 84-year - old women presented to the emergency room after she slipped and fell causing blunt traumas to the chest and face . she was conscious , hemodynamically stable and had normal blood counts besides a low albumin of 34  g / l ( 3445 the patient was on warfarin treatment due to atrial fibrillation and a history of pulmonary embolisms , and suffered furthermore from recurrent urinary tract infections and pulmonary fibrosis . initial computed tomography ( ct ) revealed a 4  cm    6  cm    15  cm paraoesophageal haematoma located in the superior and posterior mediastinum ( fig . initially the haematoma was treated conservatively but during the course of hospitalization the patient developed increasing difficulty swallowing and on the 18th day , the patient 's condition rapidly deteriorated with fever , tachycardia , acidosis and leukocytosis . an immediate ct scan showed mediastinal leakage corresponding the known location of the haematoma ( fig . 2 ) . due to mediastinal leakage and unknown consequences of stent - treating a haematoma of this size this revealed no intra- or extramural necrosis but an extremely tense haematoma and further confirmed a 3  cm longitudinal oesophageal perforation . the perforation was directly sutured ; no reinforcements were applied . until recognition of the perforation the patient was on proton pump inhibitors and soft diet , and during the post - op stay antibiotics and parenteral nutrition . the patient began full diet 10 days prior to discharge . due to a complicated post - op stay with fungal and bacterial infection we report an intramural , intrathoracic esophageal haematoma with late rupture as a result of blunt trauma to the chest . earlier cases describe intramural small bowel haematomas in patients using warfarin but our case is extremely rare . our patient 's single complaint was chest pain and although anticoagulant therapy was discontinued , late complications to haematomas are possible . likely , the perforation might be due to ischemia from the pressure built up between the haematoma , vena azygos and the distal trachea ; or the oesophageal rupture was immediate present after the trauma and the haematoma walled it off until the patient became symptomatic . early diagnosis and management of oesophageal perforation is difficult but imperial in reducing morbidity and mortality . whether surgical or conservative treatment is indicated depends mainly on the general health of the patient , time elapsed and the size of the perforation . thoracic esophageal perforations are usually differentiated in those contained within the mediastinum and those noncontained that drain into the pleural space as with our patient . primary stent treatment for spontaneus esophageal perforations especially in iatrogenic perforations has proven effective but outcomes for stent treating haematomas are unknown and require close radiographic and endoscopic follow - up . as to our knowledge , no guidelines on traumatic blunt perforations with haematomas are available , and we believe as indicated by others , that stent treatment should be reserved for patients not fit to undergo major surgery like thoracotomy , or as 2nd line management in persistent leak or sepsis once a perforation is verified management should always include antibiotics , proton pump inhibitors and parenteral nutrition as vital therapeutic measures . if choosing to treate an oesophageal hematoma conservatively we advise to stop anticoagulants or lead strict control of international normalised ratio ( inr ) when prescribing vitamin - k - antagonists . to prevent esophageal lesions , it is advisable to refrain from gastric tubes and instead consider parenteral nutrition . as with our patient , chest pain is the most frequent symptom but other symptoms such as fever , dyspnoea and dysphagia might dominate . late , spontaneous , intrathoracic esophageal perforations due to blunt trauma is to our knowledge not described previously . such haematomas can be treated conservatively but if the esophageal wall ruptures prompt surgically management must be taken , especially if uncontained .