대한흉부영상의학회 Weekly Chest Cases

Case No : 345 Date 2004-06-05

Courtesy of Kyung Joo Park, M.D. / Ajou University Medical Center, Kyoungkido, Korea
Age/Sex 59 / M
Chief ComplaintSudden dyspnea and chest pain

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Diagnosis With Brief Discussion

Diagnosis: Intramural hematoma of esophagus (developed after anticoagulation therapy)
Radiologic Findings: On initial CT images, there are no abnormal findings in the esophagus and surrounding posterior mediastinum. An aneurysm is noted in the left subclavian artery. Follow-up CT images obtained 2 days later show a tubular mass of homogeneous density with a sharp and smooth outer margin in the retrotracheal area that compresses the trachea. The esophageal lumen is not clearly identified at those levels, but the mass extends along the esophageal course up to the aortic arch level. CT scan at the left atrial level shows a normal esophagus, pleural fluid and focal atelectasis in the dependent lungs. A metallic stent is noted within the left subclavian artery.

This patient had been suffered from an aneurysm in the left subclavian artery and thrombotic arterial obstruction in the forearm. Thrombolysis was performed by intraarterial instillation of Urokinase and intravascular stent was introduced to the subclavian artery. He was treated with heparinization for 2 days.
Brief Review: Spontaneous intramural hematoma of the esophagus is probably due to spontaneous bleeding within the submucosal layer of the esophagus, usually associated with a rapid increase in intraesophageal pressure, particularly in the presence of coagulophathy. The clinical presentation is often acute retrosternal or epigastric pain accompanied by dysphagia, odynophagia, or hematemesis. The condition may mimic Mallory-Weiss syndrome, Boerhaave syndrome, acute myocardial infarction, or dissection of the thoracic aorta. Esophagogram may show narrowing of the esophageal lumen by a long, submucosal intramural mass. In cases with intramural dissection, mucosal tear or a “double-barreled esophagus” or “mucosal stripe” sign may be demonstrated. CT and MRI are useful for demonstrating esophageal mass and differentiating from other mediastinal disorders.
References: 1. Hiller N, Zagal I, Hadas-Halpern I. Spontaneous intramural hematoma of the esophagus. Am J Gastroenterol 1999; 94:2282-2284

2. Yuen EH, Yang WT, Lam WW, Kew J, Metreweli C. Spontaneous intramural hematoma of the esophagus: CT and MRI appearance. Australas Radiol 1998; 42:139-142
Keywords: Esophagus, Iatrogenic lung disease, Drug complication,

No. of Applicants : 27

▶ Correct Answer : 13/27, 48.1%

- Annecy Hospital, France Gilles Genin
- CHU Grenoble, France Mathieu Rodiere
- CHU Nancy-Brabois, France Denis Regent
- CIM Saint Dizier, France JC Leclerc
- Dong-A University Hospital, Korea Ki-Nam Lee
- Eulji hospital, Korea Jeong Joo Woo
- Geneva University Hospitals, Switzerland A.B. Younossian
- GeojeBaek Hospital, Gyungnam, Korea James Lim
- Incheon Sarang Hospital, Korea Jung Hee Kim
- Mallinckrodt Institute of Radiology, USA Jin Mo Goo
- National Taiwan University Hospital, Taiwan Tan Che Kim
- Samsung Medical Center, Korea Semin Chong
- Samsung Medical Center, Korea Sung Shine Shim

▶ Semi-Correct Answer : 5/27, 18.5%

- Asan Medical Center, Korea Eun Jin Chae
- Hanyang University Hospital, Seoul, Korea Son Youl Lee
- Homs National Hospital, Homs, Syria Rami Abou Zalaf
- Ondokuz Mayis University, Samsun, Turkey Cetin Celenk
- Social Security Hospital, Ankara, Turkey Meric Tuzun

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 345 Date 2004-06-05

Discussion

No. of Applicants : 27