S4395 A Case of Postoperative Intramural Esophageal Hematoma

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Introduction: Intramural esophageal hematomas (IEH) are rare, but important cause of acute chest pain and dysphagia and can mimic life-threatening cardiothoracic and esophageal conditions. Identification requires a high index of suspicion for timely diagnosis and appropriate management. Case Description/Methods: A 76-year-old man with hyperlipidemia, type 2 diabetes, coronary artery disease with multiple stents (on aspirin and clopidogrel), and invasive adenocarcinoma status post left upper lobe lobectomy, underwent a left chest wall desmoid fibromatosis resection. Dual-antiplatelet therapy was held 3-5 days prior to procedure. On post-operative day 3, he developed acute dysphagia and was unable to tolerate oral secretions. Urgent computed tomography (CT) scan of the chest showed a distended esophagus with debris, concerning for luminal obstruction. Esophagogastroduodenoscopy revealed a large esophageal hematoma causing mid-to-distal luminal narrowing of the esophagus, with hematin seen throughout the stomach. The patient was started on omeprazole, a nasogastric tube was placed, and diet was gradually advanced. On the day of discharge (post- esophagogastroduodenoscopy day 3), a subsequent esophagogram showed resolution of obstruction with return of normal swallow function. He was discharged on single antiplatelet therapy with aspirin. At 8-month follow-up, he reported normal swallowing and repeat chest CT showed resolution of the hematoma. Discussion: IEHs are rare entities that typically present with chest pain, dysphagia, and hematemesis and can mimic other cardiac or esophageal emergencies. They may occur spontaneously, or more commonly following esophageal instrumentation, trauma, or excessive retching and vomiting. Antiplatelet and anticoagulation therapy increases bleeding risk, predisposing patients to hematoma formation. Diagnosis is established through imaging (CT with IV contrast favored) followed by endoscopy. Esophagograms are useful to assess obstruction and swallowing function after the hematoma has been diagnosed. Most cases resolve with conservative treatment and without intervention. For this patient, esophageal stenting was deferred and conservative treatment was favored based on stable hemoglobin and successful passage of the endoscope past the hematoma. Hemoglobin remained stable following endoscopy. In this patient, the development of the IEH was likely multifactorial, including recent surgical stress and manipulation, underlying comorbidities, and recent use of dual-antiplatelet therapy.

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