Esophageal Hematoma (Bleeding Inside Esophagus Wall)

What is an esophageal hematoma?

An esophageal hematoma is a collection of blood within the wall of the esophagus (gullet). It must not be confused with a hemorrhage where blood leaks out of the organ, often into the lumen of the esophagus. The bleeding tends to occur within a layer of the esophageal wall known as the submucosa. It often arises with other conditions that affect the esophagus, like a Mallory-Weiss tear or in severe cases, a esophageal perforation (“hole” in the esophagus). Most cases of an esophageal hematoma arise as a result of vomiting or retching, typically after some other form of injury to the esophagus.

Esophageal Hematoma Incidence

An esophageal hematoma is a rare condition. Majority of the cases, about 80%, occurs in women. Its occurs as a complication in about 1 out of 400 patients undergoing transesophageal echocardiography (TEE), a diagnostic procedure to acquire ultrasound images of the heart. However, in many instances there is some underlying problem with the esophagus that predisposes it to complications like an esophageal hematoma.

Esophageal Hematoma Pathophysiology

Submucosa of the esophagus

The esophagus is an elongated narrow tube that runs from the throat to the stomach. It has a muscular wall that can stretch significantly to cater for the ball of food (bolus) that travels down it to the stomach. The wall of the esophagus is made up of 4 major layers – mucosa (innermost), submucosa just beneath it, muscularis externa and then the tuna adventitia (outermost). It is the collection of blood within the submucosa that is known as an esophageal hematoma. Since this accumulation is within the wall, it may also be referred to as an intramural hematoma.

Bleeding in the submucosa

The submucosa of the esophagus is laden with blood vessels, lymphatics and nerves. If these blood vessels rupture, blood can accumulate in the submucosa. Most cases arise with trauma although it can occur spontaneously. An erosion or ulcer in the mucosa will allow the blood to leak out into esophagus. If there is a perforation (tear in the esophagus) then blood can leak out into the thoracic cavity. This can affect the compartment containing the heart and parts of the great blood vessels known as the mediastinum, which can be life-threatening.

Esophageal Hematoma Causes

Vomiting and Retching

The most common causes of an esophageal tumor is vomiting and retching. The force generated during vomiting and retching causes strong anti-peristaltic contractions. In severe cases this can rupture the blood vessels in the submucosa and cause tears particularly in the junction between the esophagus and stomach – Mallory-Weiss tear. However, it is more likely to arise when there are certain predisposing factors.

Spontaneous Bleeding

A spontaneous esophageal hematoma means that the bleeding occurs without any previous injury or even without vomiting and retching. It is not a common occurrence and is more likely to arise in a person with a bleeding disorder. In these conditions, the body’s ability to plug up points of bleeding (clotting) is hampered and the bleeding can be continuous even without any preceding injury.

Risk factors

• Injury to the chest
• Foreign body in the esophagus
• Insertion of instrumentation like an endoscope or with endotracheal intubation
• Abrasive foods
• Ingestion of caustic substances
• Cardioversion especially if there is anticoagulant use thereafter

Esophageal Hematoma Symptoms

Initially the hematoma may be silent but as the blood accumulates and occupies space, symptoms become more evident. However, these symptoms are largely non-specific meaning that various other disorders present in the same way. The triad of symptoms of an esophageal hematoma are :

• chest pain
• difficulty swallowing (dysphagia)
• hematemesis

Chest pain

The pain is severe, behind the breastbone (retrosternal) and sometimes in the upper middle abdominal area (epigastric region). It typically worsens with swallowing (odynophagia) and persists thereafter. In most instances, the preceding trauma and vomiting causes chest pain which may be indistinguishable from the pain due to the hematoma. However, in patients with a spontaneous hematoma, the pain comes on for no apparent reason.

Swallowing problems

Difficulty swallowing (dysphagia) is a typical symptom and may be accompanied by pain  during swallowing (odynophagia). The degree of the difficulty is dependent on the severity of the condition. The chest pain is aggravate during and after swallowing. Since the esophageal pain is similar to cardiac pain, a simple sip of water will be able to differentiate from the two sites. Difficulty swallowing with pain is indicative of an esophageal problem.

Blood in the vomit

Blood in the vomit (hematemesis) is another sign of a hematoma. It is important to note that a hematoma is a collection of blood and not free bleeding (hemorrhage). However, vomiting and retching can compromise the inner mucosa and the blood can leak out. Other conditions, like a Mallory-Weiss tear, are also caused by vomiting and leads to blood in the vomit (hematemesis).

Esophageal Hematoma Diagnosis

The symptoms alone of an esophageal hematoma are not conclusive for a diagnosis. If the symptoms arise after the events described under risk factors, after severe vomiting and violent retching, or in a patient who is known to have a bleeding disorder then an esophageal hematoma should be suspected.

Tests

Blood tests may indicate an underlying causes like bleeding disorders, consequences of bleeding like anemia, or other conditions with similar symptoms like a heart attack. Imaging studies and related diagnostic procedures need to be conducted to confirm the diagnosis. These tests include :

• Upper GI endoscopy
• Barium swallow (esophagogram)
• Computed tomograph (CT) scan with contrast
• Magnetic resonance imaging (MRI)

A chest x-ray will not be conclusive for an esophageal hematoma but will confirm the accumulation of blood in the mediastinum or around the lungs.

Esophageal Hematoma Complications

The main complication that can arise is that an endoscopy may lead to a perforation when there is an existing esophageal hematoma. This perforation penetrates the entire thickness of the wall. Blood and fluids will leak out into the thorax and cause further complications which may be potentially fatal.

Esophageal Hematoma Treatment

Most esophageal hematomas resolve spontaneously. This typically occurs within 2 to 3 weeks. However, it depends on the severity of the condition. Surgery may be required in more severe cases where there is profuse blood loss. The supportive measures aimed at assisting with healing and minimizing complications include :

• Discontinue ingestion of any foods or fluids – nothing by mouth (NPO).
• Intravenous fluids should be administered during this periods.
• Drugs to suppress acid production and vomiting should be given as this can worsen the problem.
• Bleeding disorders need to be treated accordingly.
• Small amounts of food and fluid can be introduced gradually after a few days.
• Blood transfusions may be necessary for major blood loss.

Esophageal Hematoma Prognosis

The outlook with an esophageal hematoma is very good provided that a perforation is not present and does not occur. An esophageal hematoma is unlike to recur. Symptoms like pain during swallowing (odynophagia) gradually subsides after a few weeks of the condition resolving.