Q J Med 1999; 92: 123-124
© 1999 Association of Physicians
Correspondence |
Dissecting intramural haematoma of the oesophagus exacerbated by heparin therapy
John Radcliffe Hospital, Oxford
Sir,
Further to the series published by McIntyre et al.1 we would like to report a case of dissecting intramural haematoma of the oesophagus originally treated as cardiac chest pain and complicated by treatment with heparin.
A 74-year-old woman was admitted with a 30-min history of a sudden onset of central chest pain radiating to her jaw and neck, associated with sweating. She had a past medical history of hypertension and angina and was taking aspirin and lisinopril. She had not had symptoms of angina for 10 years. The pain had occurred when she had got out of bed to go to the toilet. An ambulance was called, and she was given GTN spray, following which she had a loss of consciousness, but recovered after 15 s. On arrival in hospital she continued to complain epigastric and chest pain radiating to her neck with associated waterbrash. She had a further episode of loss of consciousness with asystole recorded on the cardiac monitor, but recovery again within 20 s. On examination, she was noted to be pale and clammy with a mildly tender epigastrium. Her blood pressure was 176/79 and her pulse rate was 63 bpm. Serial ECGs revealed some minor reversible ST and T wave changes. There was no rise in serial cardiac enzymes levels. A temporary pacing wire was inserted urgently and arrangements made for transfer for permanent pacing.
The patient continued to complain of chest pain occurring in waves every 5 min which was relieved to some extent with Gaviscon liquid. She noted that the pain was worse when she ate. A heparin infusion was commenced the day after presentation, on the assumption that the chest pain was caused by coronary ischaemia. A few hours later, the patient suffered an episode of haematemesis and melaena requiring a 4-unit blood transfusion. The following day she became unable to swallow solids, although she could still manage a liquid diet. On day 6, the patient was referred for further management to the John Radcliffe Hospital where she underwent a gastroscopy. This revealed an oesophageal haematoma extending from 20 cm to the oesophagogastric junction. A chest X-ray was unremarkable, and a barium swallow confirmed a filling defect in the distal oesophagus with no leak of contrast material into the mediastinum. In view of the patient's continued dysphagia, a tunnelled line was inserted for total parenteral nutrition administration. Unfortunately this was complicated by a pneumothorax requiring a chest drain. By day 10, the patient could tolerate drinking water and by day 14, was managing a soft diet.
This case illustrates the difficulty in distinguishing the symptoms of dissecting haematoma of the oesophagus (DIHO) from cardiac pain, and the problems associated with failing to do so, DIHO is an essentially benign and almost certainly under-recognized condition characterized by a sudden onset of retrosternal chest pain, often associated with dysphagia, odynophagia and a small haematemesis.2 The condition has a distinctive endoscopic appearance with a submucosal haematoma almost invariably involving the distal oesophagus, but often extending into the middle third and occasionally the upper third of the oesophagus.3,4 It usually settles with conservative treatment within 2 weeks, and haematemesis sufficient to require blood transfusion is rare. In this patient, anticoagulation with heparin almost certainly aggravated the haematemesis and significantly delayed resolution of the condition. The clue to the diagnosis in this patient was the report of pain worse on eating on day 2, prior to treatment with heparin. Direct questioning regarding dysphagia and odynophagia in patients with atypical chest pain will reveal an occasional case of DIHO and facilitate appropriate conservative management.
References
1.
McIntyre AS, Ayres R, Atherton J, Spiller RC, Cockel R. Dissecting intramural haematoma of the oesophagus. QJ Med 1998; 91:701–5.
2. Spiller RC, Catto JVF, Kane SP. Spontaneous dissecting intramural haematoma of the oesophagus: A rare cause of haematemesis and dysphagia. Endoscopy 1981; 13:128–30.[Medline]
3.
Dumas D, Faux N, Levillain CL, Zimmerman P, Manigand G. L'hématome intra-mural spontané de l'
sophage. Une observation au cours d'un traitement anticoagulant et revue de la littérature. Med Chir Dig 1983; 12:47–50 (in French).
4. Hsu MT, Lin XZ, Chang JS, Shin JS, Chen CY, Sheu BS. Sequential endoscopic findings in spontaneous intramural haematoma of the esophagus. Endoscopy 1996; 28(5):465.[Medline]
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