The esophagus it is a tube whose length ranges from 15 to 25 cm of muscular tissue and connect the pharynx to the stomach. Histologically, it consists of several layers: the most inner layer which is mucosal layer, then submucosal layer, muscular layer, and the outermost layer which is adventitial layer. Esophageal submucosa is located between both esophageal mucosa and muscular layers, and it is comprised of blood vessels, Meissner nerve plexus and esophageal glands.
Intramural hematoma of the esophagus (IHE), or dissecting intramural hematoma, refers to a relatively rare entity that results from acute hemodynamic injuries to the layers of the esophageal mucosa and submucosa. Primary cases of IHE may present without any initial symptoms or develop following trauma, foreign body ingestion or ingestion of toxic substances or from iatrogenic sources. Patients with IHE may have symptoms that mimic other acute cardiopulmonary diseases. The class of symptoms that had commonly been attributed to IHE is acute chest pain, odynophagia, dysphagia and hematemesis.
Epidemiology
Age and Sex related:
It is estimated that women account for 80% of intramural hematomas. Affected women are mostly middle-aged. A literature study of 31 patients revealed a mean age of 67 years.
Anatomy
Pathophysiology
Vomiting may lead to raised pressure within the oesophagus which may result in mucosal tears termed Mallory-Weiss syndrome or a transmural rupture known as Boerhaave syndrome or an intramural haematoma. It usually involves the submucosa layer and is usually found in the gastrointestinal tract. Primary conditions of the esophagus such as achalasia are rare in patients with hematoma of the esophagus. In cases of esophageal hematoma, the blood can clot in various layers of the esophageal wall depending on the mechanism. For instance, vomiting-related hematoma seems to arise around the esophagogastric junction while corrosive substance related hematoma forms at areas of constriction.
Etiology
Blunt trauma
Forceful Vomiting
Endoscopy
Sclerotherapy
Barotrauma
Microvascular Damage
Genetics
Prognostic Factors
Overall, the prognosis is very good if the patient receives conservative and supportive therapy in the longer term. Episodic odynophagia is usually a self-limited condition that lasts for approximately two weeks after the onset of the first episode and is not known to relapse.
In situations that involve hematoma which causes an esophageal perforation, the patient can have severe septic complications like mediastinitis or formation of abscess.
Mortality from esophageal perforations varies between 10 to 20 percent.
Clinical History
Overall, the prognosis is very good if the patient receives conservative and supportive therapy in the longer term. Episodic odynophagia is usually a self-limited condition that lasts for approximately two weeks after the onset of the first episode and is not known to relapse.
In situations that involve hematoma which causes an esophageal perforation, the patient can have severe septic complications like mediastinitis or formation of abscess.
Mortality from esophageal perforations varies between 10 to 20 percent.
Physical Examination
Chest pain
Dysphagia and Odynophagia
Vomiting blood
Abdominal examination
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Differential Diagnoses
Esophageal Cancer
Mallory-Weiss Tear
Pulmonary Embolism (PE)
Boerhaave Syndrome
Esophageal Rupture
Myocardial Infarction
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Endoscopic Intervention: Endoscopy might be used for assessment of the severity and nature of the hematoma, as well as for possible treatment.
Endoscopic procedures can include:
Bleeding control through injection of clotting factors.
Surgical intervention through clipping or banding in cases of tears or defects in the esophageal wall.
Drainage of large hematomas.
Blood Transfusion: In cases where there is severe hemorrhage and anemia, transfusions are made to enhance the blood quantity and oxygen-carrying capacity.
Surgery: However, surgical intervention is considered in rare circumstances when the condition is serious and accompanied by such outcomes as perforation or persistent bleeding. In some cases, surgical interventions such as hematoma removal, repair of esophageal injury, or other procedures depending on the given situation, might be performed.
Treatment of Underlying Conditions: If the primary condition that led to the formation of the esophageal hematoma is coagulopathy or a bleeding disorder then the condition needs to be treated as well.
Clear Liquids and Soft Diet: If oral intake is permitted then the shift from NPO to clear liquid diets and then to a soft diet is part of the progression towards oral fluids without causing further trauma to the esophagus.
Pain Management: Appropriate measures may include stimulation relaxation activities and visual imagery or distraction activities that are ideal in the minimization of pain arising from esophageal hematoma.
Monitoring and Avoidance of Irritants: It involves the ability to recognize any cause for worsening symptoms or slowing down the healing process that needs to be avoided. One possible intervention is the elimination of certain foods and beverages from the diet to avoid causing irritation to the esophagus.
Elevating the Head of the Bed: Since gastric reflux could irritate the esophagus, trying to sleep with your head of your bed raised will decrease the chances of it.
Role of Proton pump inhibitors in treating Esophageal Hematoma
Omeprazole: Omeprazole is available as prescription and OTC preparations, and many patients use the medication in the once-daily regimen.
Esomeprazole: Like other PPIs, esomeprazole can be bought using prescription and is in the form of OTC and it is normally administered once a day.
Lansoprazole: Both the prescription and over-the-counter formulations exist and are generally consumed once daily.
Pantoprazole: The preparation of pantoprazole comes in both tablet and injectable form. The oral form is administered in the form of pills and is mostly given once a day.
Rabeprazole: It is another acid-reducing agent in the PPI category normally prescribed in a prescription formulation; it is usually administered once per day.
Role of H2-receptor antagonists in treating Esophageal Hematoma
Ranitidine:Â Blocks the histamine stimulation of H2 receptors of the gastric parietal cells, reduces the secretion of gastric acid, stomach volume, and ionized hydrogen content.
Famotidine: This competes for histamine at the H2 receptor of the gastric parietal cells and thus decreases the production of gastric acid, the volume of the stomach as well as the concentrations of hydrogen ions.
Cimetidine:Â It minimizes histamine that in turns decreases the secretion of gastric acid, the volume of the stomach as well as hydrogen ions.
Endoscopy: One of the most frequent and effective methods to access the hematoma and visualise the esophagus directly is endoscopy. Also, it might be helpful to identify the source of hematoma, such as vascular disorders or mucosal tears. Therapeutic interventions during endoscopy may include:
Bleeding control through the injection of epinephrine or the use of hemoclips in attempt to stop the bleeding.
Surgery is also required for the drainage of large hematomas or abscesses if such cases occur.
Transcatheter Embolization: It is an interventional radiology method that involves isolation of blood supply of the bleeding site by pro-arterial injection of embolic agents. This procedure may be applied to correct bleeding from esophageal vessels or other sources of hemorrhage.
Surgery: In cases of massive bleeding, perforation, or failure to respond to medical management and endoscopy, surgical management may be warranted. Surgery may consist of drainage of the hematoma, suture of the tear, ligation of bleeding points or rarely oesophagectomy.
Percutaneous Drainage: Hematomas that are large and complicated with abscess formation or infection may prompt the consider-ation of percutaneous drainage under imaging guidance to evacuate the hematoma and provide symptom relief.
use-of-phases-in-managing-esophageal-hematoma
In diagnosing cases of hematomas in the esophagus, the first step is usually to consider the patient’s symptoms such as chest pains, difficulties in swallowing and if the patient is vomiting blood. Imaging studies such as X-ray, ultrasound, computerized tomography or magnetic resonance imaging as well as endoscopy may be used to finalise diagnosis and determine the presence of other conditions or complications. The first 24 hours is primarily concerned with meeting the patient’s critical priorities which include analgesia, maintenance of hemodynamics, and control of ongoing hemorrhage. Management options may include NPO, intravenous fluids, pain relievers, anti-acid medications, and invasive procedures that involve the use of an endoscope. Conservative treatment plans are to let the hematoma mature without causing any complications over some time. Surgical management is usually advisable in the cases of recurrent bleeding, obstruction, or other complications that do not seem to improve with conservative management.
The esophagus it is a tube whose length ranges from 15 to 25 cm of muscular tissue and connect the pharynx to the stomach. Histologically, it consists of several layers: the most inner layer which is mucosal layer, then submucosal layer, muscular layer, and the outermost layer which is adventitial layer. Esophageal submucosa is located between both esophageal mucosa and muscular layers, and it is comprised of blood vessels, Meissner nerve plexus and esophageal glands.
Intramural hematoma of the esophagus (IHE), or dissecting intramural hematoma, refers to a relatively rare entity that results from acute hemodynamic injuries to the layers of the esophageal mucosa and submucosa. Primary cases of IHE may present without any initial symptoms or develop following trauma, foreign body ingestion or ingestion of toxic substances or from iatrogenic sources. Patients with IHE may have symptoms that mimic other acute cardiopulmonary diseases. The class of symptoms that had commonly been attributed to IHE is acute chest pain, odynophagia, dysphagia and hematemesis.
Age and Sex related:
It is estimated that women account for 80% of intramural hematomas. Affected women are mostly middle-aged. A literature study of 31 patients revealed a mean age of 67 years.
Vomiting may lead to raised pressure within the oesophagus which may result in mucosal tears termed Mallory-Weiss syndrome or a transmural rupture known as Boerhaave syndrome or an intramural haematoma. It usually involves the submucosa layer and is usually found in the gastrointestinal tract. Primary conditions of the esophagus such as achalasia are rare in patients with hematoma of the esophagus. In cases of esophageal hematoma, the blood can clot in various layers of the esophageal wall depending on the mechanism. For instance, vomiting-related hematoma seems to arise around the esophagogastric junction while corrosive substance related hematoma forms at areas of constriction.
Blunt trauma
Forceful Vomiting
Endoscopy
Sclerotherapy
Barotrauma
Microvascular Damage
Overall, the prognosis is very good if the patient receives conservative and supportive therapy in the longer term. Episodic odynophagia is usually a self-limited condition that lasts for approximately two weeks after the onset of the first episode and is not known to relapse.
In situations that involve hematoma which causes an esophageal perforation, the patient can have severe septic complications like mediastinitis or formation of abscess.
Mortality from esophageal perforations varies between 10 to 20 percent.
Overall, the prognosis is very good if the patient receives conservative and supportive therapy in the longer term. Episodic odynophagia is usually a self-limited condition that lasts for approximately two weeks after the onset of the first episode and is not known to relapse.
In situations that involve hematoma which causes an esophageal perforation, the patient can have severe septic complications like mediastinitis or formation of abscess.
Mortality from esophageal perforations varies between 10 to 20 percent.
Chest pain
Dysphagia and Odynophagia
Vomiting blood
Abdominal examination
Esophageal Cancer
Mallory-Weiss Tear
Pulmonary Embolism (PE)
Boerhaave Syndrome
Esophageal Rupture
Myocardial Infarction
Endoscopic Intervention: Endoscopy might be used for assessment of the severity and nature of the hematoma, as well as for possible treatment.
Endoscopic procedures can include:
Bleeding control through injection of clotting factors.
Surgical intervention through clipping or banding in cases of tears or defects in the esophageal wall.
Drainage of large hematomas.
Blood Transfusion: In cases where there is severe hemorrhage and anemia, transfusions are made to enhance the blood quantity and oxygen-carrying capacity.
Surgery: However, surgical intervention is considered in rare circumstances when the condition is serious and accompanied by such outcomes as perforation or persistent bleeding. In some cases, surgical interventions such as hematoma removal, repair of esophageal injury, or other procedures depending on the given situation, might be performed.
Treatment of Underlying Conditions: If the primary condition that led to the formation of the esophageal hematoma is coagulopathy or a bleeding disorder then the condition needs to be treated as well.
Emergency Medicine
Gastroenterology
Clear Liquids and Soft Diet: If oral intake is permitted then the shift from NPO to clear liquid diets and then to a soft diet is part of the progression towards oral fluids without causing further trauma to the esophagus.
Pain Management: Appropriate measures may include stimulation relaxation activities and visual imagery or distraction activities that are ideal in the minimization of pain arising from esophageal hematoma.
Monitoring and Avoidance of Irritants: It involves the ability to recognize any cause for worsening symptoms or slowing down the healing process that needs to be avoided. One possible intervention is the elimination of certain foods and beverages from the diet to avoid causing irritation to the esophagus.
Elevating the Head of the Bed: Since gastric reflux could irritate the esophagus, trying to sleep with your head of your bed raised will decrease the chances of it.
Emergency Medicine
Gastroenterology
Omeprazole: Omeprazole is available as prescription and OTC preparations, and many patients use the medication in the once-daily regimen.
Esomeprazole: Like other PPIs, esomeprazole can be bought using prescription and is in the form of OTC and it is normally administered once a day.
Lansoprazole: Both the prescription and over-the-counter formulations exist and are generally consumed once daily.
Pantoprazole: The preparation of pantoprazole comes in both tablet and injectable form. The oral form is administered in the form of pills and is mostly given once a day.
Rabeprazole: It is another acid-reducing agent in the PPI category normally prescribed in a prescription formulation; it is usually administered once per day.
Emergency Medicine
Gastroenterology
Ranitidine:Â Blocks the histamine stimulation of H2 receptors of the gastric parietal cells, reduces the secretion of gastric acid, stomach volume, and ionized hydrogen content.
Famotidine: This competes for histamine at the H2 receptor of the gastric parietal cells and thus decreases the production of gastric acid, the volume of the stomach as well as the concentrations of hydrogen ions.
Cimetidine:Â It minimizes histamine that in turns decreases the secretion of gastric acid, the volume of the stomach as well as hydrogen ions.
Emergency Medicine
Gastroenterology
Endoscopy: One of the most frequent and effective methods to access the hematoma and visualise the esophagus directly is endoscopy. Also, it might be helpful to identify the source of hematoma, such as vascular disorders or mucosal tears. Therapeutic interventions during endoscopy may include:
Bleeding control through the injection of epinephrine or the use of hemoclips in attempt to stop the bleeding.
Surgery is also required for the drainage of large hematomas or abscesses if such cases occur.
Transcatheter Embolization: It is an interventional radiology method that involves isolation of blood supply of the bleeding site by pro-arterial injection of embolic agents. This procedure may be applied to correct bleeding from esophageal vessels or other sources of hemorrhage.
Surgery: In cases of massive bleeding, perforation, or failure to respond to medical management and endoscopy, surgical management may be warranted. Surgery may consist of drainage of the hematoma, suture of the tear, ligation of bleeding points or rarely oesophagectomy.
Percutaneous Drainage: Hematomas that are large and complicated with abscess formation or infection may prompt the consider-ation of percutaneous drainage under imaging guidance to evacuate the hematoma and provide symptom relief.
Emergency Medicine
Gastroenterology
In diagnosing cases of hematomas in the esophagus, the first step is usually to consider the patient’s symptoms such as chest pains, difficulties in swallowing and if the patient is vomiting blood. Imaging studies such as X-ray, ultrasound, computerized tomography or magnetic resonance imaging as well as endoscopy may be used to finalise diagnosis and determine the presence of other conditions or complications. The first 24 hours is primarily concerned with meeting the patient’s critical priorities which include analgesia, maintenance of hemodynamics, and control of ongoing hemorrhage. Management options may include NPO, intravenous fluids, pain relievers, anti-acid medications, and invasive procedures that involve the use of an endoscope. Conservative treatment plans are to let the hematoma mature without causing any complications over some time. Surgical management is usually advisable in the cases of recurrent bleeding, obstruction, or other complications that do not seem to improve with conservative management.
The esophagus it is a tube whose length ranges from 15 to 25 cm of muscular tissue and connect the pharynx to the stomach. Histologically, it consists of several layers: the most inner layer which is mucosal layer, then submucosal layer, muscular layer, and the outermost layer which is adventitial layer. Esophageal submucosa is located between both esophageal mucosa and muscular layers, and it is comprised of blood vessels, Meissner nerve plexus and esophageal glands.
Intramural hematoma of the esophagus (IHE), or dissecting intramural hematoma, refers to a relatively rare entity that results from acute hemodynamic injuries to the layers of the esophageal mucosa and submucosa. Primary cases of IHE may present without any initial symptoms or develop following trauma, foreign body ingestion or ingestion of toxic substances or from iatrogenic sources. Patients with IHE may have symptoms that mimic other acute cardiopulmonary diseases. The class of symptoms that had commonly been attributed to IHE is acute chest pain, odynophagia, dysphagia and hematemesis.
Age and Sex related:
It is estimated that women account for 80% of intramural hematomas. Affected women are mostly middle-aged. A literature study of 31 patients revealed a mean age of 67 years.
Vomiting may lead to raised pressure within the oesophagus which may result in mucosal tears termed Mallory-Weiss syndrome or a transmural rupture known as Boerhaave syndrome or an intramural haematoma. It usually involves the submucosa layer and is usually found in the gastrointestinal tract. Primary conditions of the esophagus such as achalasia are rare in patients with hematoma of the esophagus. In cases of esophageal hematoma, the blood can clot in various layers of the esophageal wall depending on the mechanism. For instance, vomiting-related hematoma seems to arise around the esophagogastric junction while corrosive substance related hematoma forms at areas of constriction.
Blunt trauma
Forceful Vomiting
Endoscopy
Sclerotherapy
Barotrauma
Microvascular Damage
Overall, the prognosis is very good if the patient receives conservative and supportive therapy in the longer term. Episodic odynophagia is usually a self-limited condition that lasts for approximately two weeks after the onset of the first episode and is not known to relapse.
In situations that involve hematoma which causes an esophageal perforation, the patient can have severe septic complications like mediastinitis or formation of abscess.
Mortality from esophageal perforations varies between 10 to 20 percent.
Overall, the prognosis is very good if the patient receives conservative and supportive therapy in the longer term. Episodic odynophagia is usually a self-limited condition that lasts for approximately two weeks after the onset of the first episode and is not known to relapse.
In situations that involve hematoma which causes an esophageal perforation, the patient can have severe septic complications like mediastinitis or formation of abscess.
Mortality from esophageal perforations varies between 10 to 20 percent.
Chest pain
Dysphagia and Odynophagia
Vomiting blood
Abdominal examination
Esophageal Cancer
Mallory-Weiss Tear
Pulmonary Embolism (PE)
Boerhaave Syndrome
Esophageal Rupture
Myocardial Infarction
Endoscopic Intervention: Endoscopy might be used for assessment of the severity and nature of the hematoma, as well as for possible treatment.
Endoscopic procedures can include:
Bleeding control through injection of clotting factors.
Surgical intervention through clipping or banding in cases of tears or defects in the esophageal wall.
Drainage of large hematomas.
Blood Transfusion: In cases where there is severe hemorrhage and anemia, transfusions are made to enhance the blood quantity and oxygen-carrying capacity.
Surgery: However, surgical intervention is considered in rare circumstances when the condition is serious and accompanied by such outcomes as perforation or persistent bleeding. In some cases, surgical interventions such as hematoma removal, repair of esophageal injury, or other procedures depending on the given situation, might be performed.
Treatment of Underlying Conditions: If the primary condition that led to the formation of the esophageal hematoma is coagulopathy or a bleeding disorder then the condition needs to be treated as well.
Emergency Medicine
Gastroenterology
Clear Liquids and Soft Diet: If oral intake is permitted then the shift from NPO to clear liquid diets and then to a soft diet is part of the progression towards oral fluids without causing further trauma to the esophagus.
Pain Management: Appropriate measures may include stimulation relaxation activities and visual imagery or distraction activities that are ideal in the minimization of pain arising from esophageal hematoma.
Monitoring and Avoidance of Irritants: It involves the ability to recognize any cause for worsening symptoms or slowing down the healing process that needs to be avoided. One possible intervention is the elimination of certain foods and beverages from the diet to avoid causing irritation to the esophagus.
Elevating the Head of the Bed: Since gastric reflux could irritate the esophagus, trying to sleep with your head of your bed raised will decrease the chances of it.
Emergency Medicine
Gastroenterology
Omeprazole: Omeprazole is available as prescription and OTC preparations, and many patients use the medication in the once-daily regimen.
Esomeprazole: Like other PPIs, esomeprazole can be bought using prescription and is in the form of OTC and it is normally administered once a day.
Lansoprazole: Both the prescription and over-the-counter formulations exist and are generally consumed once daily.
Pantoprazole: The preparation of pantoprazole comes in both tablet and injectable form. The oral form is administered in the form of pills and is mostly given once a day.
Rabeprazole: It is another acid-reducing agent in the PPI category normally prescribed in a prescription formulation; it is usually administered once per day.
Emergency Medicine
Gastroenterology
Ranitidine:Â Blocks the histamine stimulation of H2 receptors of the gastric parietal cells, reduces the secretion of gastric acid, stomach volume, and ionized hydrogen content.
Famotidine: This competes for histamine at the H2 receptor of the gastric parietal cells and thus decreases the production of gastric acid, the volume of the stomach as well as the concentrations of hydrogen ions.
Cimetidine:Â It minimizes histamine that in turns decreases the secretion of gastric acid, the volume of the stomach as well as hydrogen ions.
Emergency Medicine
Gastroenterology
Endoscopy: One of the most frequent and effective methods to access the hematoma and visualise the esophagus directly is endoscopy. Also, it might be helpful to identify the source of hematoma, such as vascular disorders or mucosal tears. Therapeutic interventions during endoscopy may include:
Bleeding control through the injection of epinephrine or the use of hemoclips in attempt to stop the bleeding.
Surgery is also required for the drainage of large hematomas or abscesses if such cases occur.
Transcatheter Embolization: It is an interventional radiology method that involves isolation of blood supply of the bleeding site by pro-arterial injection of embolic agents. This procedure may be applied to correct bleeding from esophageal vessels or other sources of hemorrhage.
Surgery: In cases of massive bleeding, perforation, or failure to respond to medical management and endoscopy, surgical management may be warranted. Surgery may consist of drainage of the hematoma, suture of the tear, ligation of bleeding points or rarely oesophagectomy.
Percutaneous Drainage: Hematomas that are large and complicated with abscess formation or infection may prompt the consider-ation of percutaneous drainage under imaging guidance to evacuate the hematoma and provide symptom relief.
Emergency Medicine
Gastroenterology
In diagnosing cases of hematomas in the esophagus, the first step is usually to consider the patient’s symptoms such as chest pains, difficulties in swallowing and if the patient is vomiting blood. Imaging studies such as X-ray, ultrasound, computerized tomography or magnetic resonance imaging as well as endoscopy may be used to finalise diagnosis and determine the presence of other conditions or complications. The first 24 hours is primarily concerned with meeting the patient’s critical priorities which include analgesia, maintenance of hemodynamics, and control of ongoing hemorrhage. Management options may include NPO, intravenous fluids, pain relievers, anti-acid medications, and invasive procedures that involve the use of an endoscope. Conservative treatment plans are to let the hematoma mature without causing any complications over some time. Surgical management is usually advisable in the cases of recurrent bleeding, obstruction, or other complications that do not seem to improve with conservative management.
Both our subscription plans include Free CME/CPD AMA PRA Category 1 credits.
Digital Certificate PDF
On course completion, you will receive a full-sized presentation quality digital certificate.
medtigo Simulation
A dynamic medical simulation platform designed to train healthcare professionals and students to effectively run code situations through an immersive hands-on experience in a live, interactive 3D environment.
medtigo Points
medtigo points is our unique point redemption system created to award users for interacting on our site. These points can be redeemed for special discounts on the medtigo marketplace as well as towards the membership cost itself.
Community Forum post/reply = 5 points
*Redemption of points can occur only through the medtigo marketplace, courses, or simulation system. Money will not be credited to your bank account. 10 points = $1.
All Your Certificates in One Place
When you have your licenses, certificates and CMEs in one place, it's easier to track your career growth. You can easily share these with hospitals as well, using your medtigo app.
