Case report Br. J. Surg. 1992, Vol. 79, August, 781

Total dysphagia from intramural haematoma following sclerotherapy for oesophageal va r ices J. P. McGrath, T. N. WaIsh and T. P. J. Hennessy University Department of Surgery, St James's Hospital, Trinity College, Dublin 8, Ireland Correspondence to: Professor T. P. J. Hennessy

Oesophageal intramural haematoma is rare, but it has been reported after emesis, Mallory- Weiss tears and in association with trauma. It also occurs spontaneously. Presenting symptoms are dysphagia, odynophagia, haematemesis and chest pain. A patient is reported with intramural haematoma following elective injection sclerotherapy and presenting with acute dysphagia.

Case report A 59-year-old man was admitted for elective injection sclerotherapy for oesophageal varices secondary to alcoholic hepatic cirrhosis. He had presented initially 5 months earlier with severe haematemesis, when varices were identified and injected. The patient had undergone four further sessions of sclerotherapy over a 2-month period with an uneventful outcome. On his fifth presentation, varices were injected with 15 ml ethanolamine oleate through a rigid oesophagoscope. Over the following 18 h the patient complained of progressive chest tightness and dysphagia. Results of clinical examination were normal and vital signs remained stable. Electrocardiography and chest radiography showed no abnormality but a Gastrografin (Schering Health Care, Burgess Hill, U K ) swallow demonstrated compression of the entire wall of the oesophagus resulting in proximal hold-up. Computed tomography revealed an intramural soft tissue mass extending from the aortic arch to the diaphragm and compressing the lumen (Figure I ). The soft tissue was of the same density as the aorta, confirming the clinical impression of an intramural haematoma. The patient was managed conservatively and his symptoms settled within 72 h. At follow-up endoscopy 3 months later there was no evidence of stenosis and no further complications occurred at subsequent sclerotherapy.

Figure 1 Computed tomographic scan o j thorax show'ing oesophageul lumen (open arrow) compressed and partially occluded by an intramural haematoma

one case in 304 patients receiving a total of 1336 injections. There have been few other reports of intramural haematoma complicating injection sclerotherapy. Post-mortem studies have demonstrated that tissue necrosis associated with injection of sclerosant can extend deep into the submucosa and muscularis. It has been suggested that raised portasystemic pressure and haemostatic defects, in addition to submucosal necrosis, can result in dissection4. Symptoms of severe complete dysphagia may suggest the diagnosis. The possibility of haematoma may also be raised by retrosternal pain, although this is more frequently the result of tissue necrosis. Management should be conservative as symptoms usually begin to resolve spontaneously over 36-72 h and disappear completely in 2-3 weeks. Skillington et a/.' reported an iatrogenic perforation during endoscopic examination of an intramural haematoma, which necessitated oesophagectomy. Further injection sclerotherapy is not contraindicated: it has been suggested that the submucosal healing along the dissection plane may aid in the obliteration of residual varices.

References 1. 2.

Discussion Sclerotherapy has become the treatment of choice for oesophageal varices, but there is no consensus as to whether the sclerosant should be injected into the varices or the perivariceal tissues; both approaches appear to be equally effective'. While some intraluminal bleeding is inevitable, it is rarely serious. Intramural haematoma is, however, rare. Anticoagulant therapy, impaired coagulation and thrombocytopenia complicating leukaemia and aplastic anaemia have all been described as contributing factors. Desmorat et al.' reported three cases, an incidence of 1.6 per cent, but Kahn et a / . 3 reported only

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3. 4. 5.

Spence RAJ, Johnston GW. Oesophageal varices: pathogenesis and management. In: Russell RCG, ed. Recent Adw2nce.s in Surgery. Vol. 12. London: Churchill Livingstone, 1986: 105-23. Desmorat H , Cales P, Vine1 JP. Obstructive intramural haematoma of the oesophagus: an unusual complication of endoscopic variceal sclerotherapy. Gastroenterol CIin Biol 1990; 14: 581-5. Kahn D, Jones B, Bornman PL, Terblanche J. Incidence and management of complications after injection sclerotherapy: a ten year prospective evaluation. Surgery 1989; 105: 160-5. Low DE, Patterson DJ. Complete esophageal obstruction secondary to dissecting intramural haematoma after endoscopic variceal sclerotherapy. A m J Gastroenterol 1988; 83: 435-8. Skillington PD, Matar KS, Gardner MA, Pdrkes RP, Cole PH. Intramural haematoma complicated by perforationr. Aust N Z J Sury 1989; 59: 430-2.

Paper accepted 18 February 1992

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Total dysphagia from intramural haematoma following sclerotherapy for oesophageal varices.

Case report Br. J. Surg. 1992, Vol. 79, August, 781 Total dysphagia from intramural haematoma following sclerotherapy for oesophageal va r ices J. P...
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