Intramural hematoma of the esophagus mimicking hemorrhaging esophageal cancer
A 77-year-old male presented with severe epigastric pain, hematemesis, hemorrhagic shock and respiratory failure due to aspiration. Apart from a two-week history of intermittent epigastric pain, there was no recent history of dysphagia, weight loss or anorexia. His past history includes a previous stroke, for which he took clopidogrel regularly. He was intubated for ventilatory support immediately. Blood products were also administered. Physical examination was unremarkable except for bibasal crackles. Gastroscopy was performed to achieve hemostasis. It revealed marked luminal occlusion by diffuse mucosal ulceration with active ooze, suspected to be malignancy (). A biopsy was taken for histological examination. After stabilization, a computed tomography (CT) scan with intravenous contrast revealed a thickened esophagus extending from T1 down to the stomach near to the gastro-esophageal junction (). The esophageal lumen was almost completely obliterated.\nThe diagnosis of intramural hematoma of esophagus (IHE) was made based on the history of anti-coagulant use and CT finding of esophageal wall thickening without any evidence of perforation. This was further supported by histological confirmation of esophagitis. He was conservatively managed; nutrition was provided parenterally, and continued to remain stable. He recovered from aspiration pneumonia over the next few days and was extubated. Repeat gastroscopy demonstrated an intact esophagus with small areas of linear superficial ulceration and scarring consistent with healing tear (). He was discharged on soft pureed diet for two weeks and remained asymptomatic at twelve-week follow up.