Unusual Chest Pain
Yang-Yuan Chen M.D., Wen-Pang Su M.D.,
Hsin-Yuan Fang M.D.
1Division of Gastroenterology, Chest surgery1
China Medical University Hospital, China Medical University, Taichung, Taiwan
.
Correspondence and Reprints: Yang-Yuan Chen, M.D. China Medical University, China Medical University Hospital 3 Lane 138 Tai-An 2nd Street Changhua, 500 TAIWAN Fax: +886-4-7228289 E-mail: [email protected] Grant Support: The authors received no grant support for this manuscript.
Disclosures: The authors have no potential conflict of interest to disclose. Writing Assistance: Nil
Yang-Yuan Chen M.D.
Writing and final approval of this manuscript.
Department of Gastroenterology, China Medical University Hospital, China Medical University, Taiwan.
E-mail: ychen02@ gmail.com
Wen-Pang Su M.D., Hsin-Yuan Fang M.D.
Writing of this manuscript.
Department of Gastroenterology, China Medical University Hospital, China Medical University, Taiwan.
E-mail: D180 4 [email protected]
• A 49-year-old male with a past history for type II diabetes mellitus and hypertension presented with one week history of chest pain, odynophagia, and dysphagia. The chest pain suddenly attacked at 2 weeks ago. He first aided at another hospital and computed tomography (CT) scan revealed focal fluid
accumulation submucosal of upper third esophagus (Fig. A, block arrow) and air leakage to mediastinum (Fig. A, white arrow). He had a negative barium esophagogram on hospital day 2 (Fig. B). He received nothing per mouth, intravenous fluid hydration, and antibiotics. He was referred to our ward due to no improvement of chest pain. He suddenly suffered more severe chest pain on hospital day 2. An emergency CT scan of the chest and reconstruction revealed extensive submucosal air dissecting circumferentially around the lumen of the esophagus extending along the length of the esophagus with fluid accumulation (Fig. 3, 4 , black arrow) and extra-esophageal air and fluid leakage (Fig. 3, 4 , white arrow). He also had high fever and more odynophagia and dysphagia. His laboratory test revealed white blood cell count 9.2 g/dL with segment 73% and elevated C-reaction protein 11.52 mg/dL. An emergency chest surgery was consulted and operation.
Answer: Intramural Esophageal Dissection Associated
Esophageal Perforation
The dissection segment was surgical incision with pus discharge (Fig. E) and an esophagogastric anastomosis was construction. He was discharged without complication 2 weeks later.
Intramural esophageal dissection (IED) is extremely rare disorder caused by transverse and longitudinal separation of the mucosal and submucosal layers of the esophageal wall. There are fewer 50 reported cases, since first case was described in 1968.1 The incidence will be increased in recent years when
advanced therapeutic endoscopy induced iatrogenic injury and routine use CT scan for detection of IED.
The etiologies of IDE include iatrogenic endoscopic intervention, mucosal injury by ingested sharp foreign body, and spontaneous who especial on liver cirrhosis, anticoagulant agent, or coagulopathy patients. Patients usually suddenly present with chest pain, odynophagia, and dysphagia. Esophageal intramural hematoma shall be differential diagnosis when the symptoms suffer after therapeutic endoscopy.2 CT scan has proven useful for the detection of IDE
which showed true lumen surrounded by false lumen. IED is usually as a contained injury without perforation. There are only 3 cases included our case reported IED with perforation into mediastinum.3
Management of the IED is conservative including nothing per mouth and broad-spectrum antibiotics. Therapeutic endoscopy with incision of the mucosa will short the hospitalization and consider as alternative treatment. Surgery shall be performed on patients who fail to conservative or therapeutic endoscopic treatment and on those with perforation, as in this case. 1. 3 The prognosis is good
References:
1. Stephens NA, Shah SK, Walker PA, Jayanty V, Raijman I, Khalil K. Recurrent spontaneous esophageal dissection. JSLS. 2014; 18(2): 342-5. 2. Yen HH, Soon MS, Chen YY. Esophageal intramural hematoma: an unusual
complication of endoscopic biopsy. Gastrointest Endosc. 2005; 62(1): 161-3. 3. Monu NC, Murphy BL. Intramural esophageal dissection associated with
