ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Unusual Chest Pain Yang-Yuan Chen, Wen-Pang Su, and Hsin-Yuan Fang Division of Gastroenterology, Chest Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
Question: A 49-yearold man with a history of type II diabetes mellitus and hypertension complained of chest pain, odynophagia, and dysphagia since 2 weeks. The patient suffered sudden chest pain 2 weeks ago. He had visited another hospital and underwent CT, which revealed focal fluid accumulation in the submucosal layer of the upper third of the esophagus (Figure A, black arrow) and air leakage into the mediastinum (Figure A, white arrow). A barium esophagogram performed on day 2 of hospitalization was negative (Figure B). He received nothing by mouth, intravenous fluid hydration, and antibiotics. He was referred to our institution because of no improvement in the chest pain. The chest pain worsened on day 2 of hospitalization. An emergency chest CT and reconstruction revealed extensive air dissection in the submucosal layer around the circumference of the esophageal lumen, which extended along the esophageal length with fluid accumulation (Figure C, D, black arrow) and extraesophageal air and fluid leakage (Figure C, D, white arrow). In addition, the patient developed high fever with severe odynophagia and dysphagia. A laboratory examination revealed a white blood cell count of 9.2 g/dL with segment 73% and elevated C-reaction protein levels of 11.52 mg/dL. Thus, emergency chest surgery was advised and performed. What is the diagnosis?
Gastroenterology 2015;148:e7–e9
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.10.048
e8
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 4: Intramural Esophageal Dissection-Associated Esophageal Perforation The dissection segment was surgically incised with pus discharge (Figure E), and an esophagogastric anastomosis was constructed. The patient was discharged after 2 weeks with no complications. Intramural esophageal dissection (IED) is an extremely rare disorder caused by a transverse and longitudinal separation of the mucosal and submucosal layers of the esophageal wall. Fewer than 50 IED cases have been reported since the description of the first such case in 1968.1 The incidence of IED has increased in recent years because of advanced therapeutic endoscopy-induced iatrogenic injuries, in addition to the routine use of CT for the diagnosis of IED. The etiologies of IED include iatrogenic endoscopic intervention, mucosal injury sustained through the ingestion of a sharp foreign body, and spontaneous, particularly in patients with liver cirrhosis or coagulopathy or those receiving anticoagulant therapy. The differential diagnosis may include esophageal intramural hematoma when the symptoms develop after therapeutic endoscopy.2 CT has proven useful for the diagnosis of IED. IED usually presents as a contained injury without perforation. To date, only 3 cases, including the present case, of IED with perforation into the mediastinum have been reported.3 Management includes conservative treatment with nothing by mouth and broad-spectrum antibiotics. Therapeutic endoscopy with a mucosal incision shortens the duration of hospitalization. Surgery can be performed in patients who do not respond favorably to conservative treatment or therapeutic endoscopy and those with perforations,1,3 as in the present case. The prognosis is usually good.
References 1. 2. 3.
Stephens NA, Shah SK, Walker PA, et al. Recurrent spontaneous esophageal dissection. JSLS 2014;18:342–345. Yen HH, Soon MS, Chen YY. Esophageal intramural hematoma: an unusual complication of endoscopic biopsy. Gastrointest Endosc 2005;62:161–163. Monu NC, Murphy BL. Intramural esophageal dissection associated with esophageal perforation. R I Med J 2013; 96:44–46.
e9
Question: A 49-yearold man with a history of type II diabetes mellitus and hypertension complained of chest pain, odynophagia, and dysphagia since 2 weeks. The patient suffered sudden chest pain 2 weeks ago. He had visited another hospital and underwent CT, which revealed focal fluid accumulation in the submucosal layer of the upper third of the esophagus (Figure A, black arrow) and air leakage into the mediastinum (Figure A, white arrow). A barium esophagogram performed on day 2 of hospitalization was negative (Figure B). He received nothing by mouth, intravenous fluid hydration, and antibiotics. He was referred to our institution because of no improvement in the chest pain. The chest pain worsened on day 2 of hospitalization. An emergency chest CT and reconstruction revealed extensive air dissection in the submucosal layer around the circumference of the esophageal lumen, which extended along the esophageal length with fluid accumulation (Figure C, D, black arrow) and extraesophageal air and fluid leakage (Figure C, D, white arrow). In addition, the patient developed high fever with severe odynophagia and dysphagia. A laboratory examination revealed a white blood cell count of 9.2 g/dL with segment 73% and elevated C-reaction protein levels of 11.52 mg/dL. Thus, emergency chest surgery was advised and performed. What is the diagnosis?
Gastroenterology 2015;148:e7–e9
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.10.048
e8
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 4: Intramural Esophageal Dissection-Associated Esophageal Perforation The dissection segment was surgically incised with pus discharge (Figure E), and an esophagogastric anastomosis was constructed. The patient was discharged after 2 weeks with no complications. Intramural esophageal dissection (IED) is an extremely rare disorder caused by a transverse and longitudinal separation of the mucosal and submucosal layers of the esophageal wall. Fewer than 50 IED cases have been reported since the description of the first such case in 1968.1 The incidence of IED has increased in recent years because of advanced therapeutic endoscopy-induced iatrogenic injuries, in addition to the routine use of CT for the diagnosis of IED. The etiologies of IED include iatrogenic endoscopic intervention, mucosal injury sustained through the ingestion of a sharp foreign body, and spontaneous, particularly in patients with liver cirrhosis or coagulopathy or those receiving anticoagulant therapy. The differential diagnosis may include esophageal intramural hematoma when the symptoms develop after therapeutic endoscopy.2 CT has proven useful for the diagnosis of IED. IED usually presents as a contained injury without perforation. To date, only 3 cases, including the present case, of IED with perforation into the mediastinum have been reported.3 Management includes conservative treatment with nothing by mouth and broad-spectrum antibiotics. Therapeutic endoscopy with a mucosal incision shortens the duration of hospitalization. Surgery can be performed in patients who do not respond favorably to conservative treatment or therapeutic endoscopy and those with perforations,1,3 as in the present case. The prognosis is usually good.
References 1. 2. 3.
Stephens NA, Shah SK, Walker PA, et al. Recurrent spontaneous esophageal dissection. JSLS 2014;18:342–345. Yen HH, Soon MS, Chen YY. Esophageal intramural hematoma: an unusual complication of endoscopic biopsy. Gastrointest Endosc 2005;62:161–163. Monu NC, Murphy BL. Intramural esophageal dissection associated with esophageal perforation. R I Med J 2013; 96:44–46.
e9
