A young man with chest pain on swallowing...
Your patient is a young male who presents with substernal chest pain. He reports having outpatient back surgery earlier that day. He is an excellent historian and reports that the
surgery was initially attempted via LMA intubation; however, because of secretions, he required emergent endotracheal intubation and placement of an OG-tube. He states that he awoke from surgery with a substernal chest pain that has persisted since then. He tried eating a meal following surgery and had severe pain with swallowing. His initial CXR is shown below.
A chest CT is obtained.
Interpret the image. What do you think the diagnosis is? What would be your next steps in management.
Scroll down for the Case Conclusion.
Final diagnosis: Iatrogenic focal esophageal dissection
Case Conclusion: The CT of the chest identified a local injury to the posterior esophagus in the proximal thoracic esophagus with gas seen dissecting along the esophagus. No mediastinal air or fluid was seen and there was no pleural effusion to suggest through and through perforation. The patient was started on antibiotics and a thoracic surgery consult was obtained. The patient had a barium esophagram that demonstrated no leak. The patient was admitted and observed on the thoracic surgery service where he was placed on a clear liquid diet for a week. He was seen in follow-up a month later. At that time, he was doing well with no evidence of stricture on a follow-up esophagram.
Learning Points: When evaluating any patient, it is always important to consider any recent procedures or interventions as the differential diagnosis often expands when considering the possibility of iatrogenic complication. Since not all patients walk up the front desk and say “I was emergently intubated this morning and then developed terrible chest pain”, it is always important to ask (and do the chart biopsy).
When it comes to esophageal emergencies, spontaneous and iatrogenic etiologies are both common. Spontaneous injury usually happens in the context of forceful vomiting or retching causing sudden increase in pressure in the lower esophagus, while iatrogenic injury is usually the result of endoscopic procedures and less commonly due to nasogastric tube placement [1,2,3,4]. Often, these happen in the context of difficult (such as those with pre-existing anatomic abnormalities) or emergent/rushed procedures.
There is a spectrum of injuries to the esophageal mucosa, ranging from small tears such as Mallory Weiss to frank esophageal perforation. Intramural esophageal dissection lies between these two extremes. It occurs when a hematoma forms between the mucosal and muscular layers of the esophagus that extends in the submucosal plane, stripping off the esophageal mucosa [1]. Since the inciting factor is hematoma formation, patients on anticoagulation are at higher risk for spontaneous occurrence [2]. The most common presenting symptoms are sudden, severe retrosternal chest pain, hematemesis, odynophagia and dysphagia [1]. CT is the current chest of choice to make the diagnosis. A “double barrel” esophagus is diagnostic of intramural esophageal dissection [5]. If a esophageal dissection diagnosis is made, a follow-up study with oral contrast such as an esophagram is indicated to determine if there is an esophageal leak as this determines subsequent management [2]. A barium esophagram may demonstrate a “mucosal stripe” sign, highlighting the false esophageal lumen.
Unlike frank esophageal perforation (such as Boerhaave’s syndrome) which is managed with broad spectrum antibiotics and emergent surgery, esophageal dissection is managed much more conservatively with prophylactic antibiotics, proton pump inhibitor, and nothing by mouth in the acute period. It rarely progresses to esophageal perforation.
Case Conclusion by Maia Dorsett (@maiadorsett)
References
- Hanson, J. M., Neilson, D., & Pettit, S. H. (1991). Intramural oesophageal dissection. Thorax, 46(7), 524-527.
- Beumer, J. D., Devitt, P. G., & Thompson, S. K. (2010). Intramural oesophageal dissection. ANZ journal of surgery, 80(1‐2), 91-95.
- Tang, S. J., Tang, L., Jazrawi, S. F., Meyer, D., Wait, M. A., & Myers, L. L. (2009). Iatrogenic esophageal submucosal dissection after attempted diagnostic gastroscopy (with videos). The Laryngoscope, 119(1), 36-38.
- Prabhakaran, S., Doraiswamy, V. A., Nagaraja, V., Cipolla, J., Ofurum, U., Evans, D. C., ... & Jaik, N. P. (2012). Nasoenteric tube complications. Scandinavian Journal of Surgery, 101(3), 147-155.
- Valenzuela, D. M., Behr, S. C., Coakley, F. V., Wang, Z. J., Webb, E. M., & Yeh, B. M. (2014). Computed Tomography of Iatrogenic Complications of Upper Gastrointestinal Endoscopy, Stenting, and Intubation. Radiologic Clinics of North America, 52(5), 1055-1070.