대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Iatrogenic Submucosal Dissection of the Esophagus

Radiologic Findings

View of the mediastinum from CT scan shows the centrally located true lumen surrounded by a mucosal flap, which is separated from presumed muscular layer by the false lumen. No pleural effusion, mediastinal fluid or mediastinal free air is present. Esophagogram was normal (not shown).

Brief Review

There are three different types of acute esophageal trauma: Boerhaave’s syndrome, Mallory-Weiss syndrome, and submucosal dissection of the esophagus. The last one, which is rare, was first described in 1968 by Marks and Keet. There are several different terminologies for this condition: intramural rupture, esophageal apoplexy, submucosal or intramural dissection, and intramural hematoma. It usually occurs spontaneously with or without mucosal laceration, hence the term spontaneous submucosal dissection of the esophagus. However, not all cases of this condition occurs spontaneously. For instance, this rare disease may complicate mycobacterial infection in patients at risk for AIDS or endoscopic injection sclerotherapy. No report was available concerning cases caused by gastrofiberscopy.
The most common presenting symptom is severe chest pain. As in Mallory-Weiss syndrome, treatment is conservative and the prognosis is excellent. However, Jung and Lee recently proposed close follow-up for an extensive dissection.
The “mucosal stripe sign” had been suggested as a radiologic finding as early as in 1969. Reported esophagographic findings include a long, smooth filling defect in the mid- and lower esophagus on the poseterior wall and "double-barreled" esophagus. CT can show eccentric thickening of the esophageal wall, double lumens formed by mucosal flaps, low or high attenuation intramural hematoma, or walled-off paraesophageal low density.
In the present case, although endoscopy has not been performed again, anatomic abnormalities demonstrated by CT was straightforward enough to lead to the diagnosis.Symptoms and signs of the patient disappeared completely after four days of conservative treatment.

References

1. Marks IN, Keet AD. Intramural rupture of the oesophagus. BMJ 1968;3:536-537
2. Jung KW, Lee OJ. Extensive spontaneous submucoal dissection of the esophagus: long-term sequential endoscopic observation and treatment. Gastrointest Endosc 2000;55:262-265
3. Hsu CC, Changchien CS. Endoscopic and radiological features of intramural esophageal dissection. Endoscopy. 2001 Apr;33:379-381
4. Lee KS, Kim IY, Kim PN. Dissecting intramural hematoma of the esophagus in Boerhaave syndrome: CT findings. AJR 1991;157:197-198
5. R de Silva, Stoopack PM, Raufman JP. Esophageal fistulas associated with mycobacterial infection in patients at risk for AIDS. Radiology 1990 175: 449-453
6. Agha FP. The esophagus after endoscopic injection sclerotherapy: acute and chronic changes Radiology 1984 153: 37-42

Keywords

Esophagus, Trauma, iatrogenic,