Food-Induced Severe Chest Pain and Hematemesis
Article Outline
- Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 1580): Esophageal Apoplexy
- References
- Copyright
Question: An 88-year-old woman ate dry, crispy Yorkshire pudding causing slight epigastric pain. Thirty minutes later she developed sudden-onset, severe, central chest pain radiating to the back and epigastrium, associated with shortness of breathe and bouts of hematemesis. She had a background of mild gastritis and reflux esophagitis for which she was taking omeprazole.
On examination, pulse was regular (84 bpm) with no radio-radial delay and blood pressure equal bilaterally. The abdomen was soft with mild epigastric tenderness. Cardiovascular and respiratory examinations were unremarkable. On investigation her blood tests (including full blood count, clotting screen, renal/liver function, and serum amylase), electrocardiogram and chest/abdominal radiographs were normal. However, emergency chest computed tomography (Figure A) detected swelling of the entire esophagus (arrow) presumed secondary to an incarcerated small hiatal hernia. The thoracic aorta was normal.
The patient underwent emergency esophagoscopy (Figure B) revealing extensive confluent ulceration involving the esophagus from the level of the cricopharyngeus to the lower third associated with epiglottis and erythema of the vocal cords. Esophageal blood clots were present, which extended submucosally and widespread slow bleeding was observed precluding biopsy. No varices or hiatal hernia were identified. The patient was treated conservatively and discharged 14 days later. At 2 weeks follow-up, she was well and repeat esophagoscopy considered unnecessary.
What is the diagnosis?
Look on page 1860 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 1580): Esophageal Apoplexy
This patient presented with a classic picture of esophageal apoplexy or submucosal esophageal dissection. This relatively uncommon condition presents with a triad of symptoms; odynophagia, severe retrosternal chest pain and hematemesis, often associated with an upper respiratory tract infection.
Esophageal apoplexy can occur either spontaneously or secondary to foreign body ingestion. However, the etiology remains unclear. It has been hypothesized that foreign body ingestion stimulates formation of a submucosal hematoma secondary to abrasive forces. In turn, the resultant pressure causes hematoma extension within the intramural space, potentially involving the entire esophageal length, and finally submucosal tearing allowing decompression into the esophageal lumen. In addition, the common occurrence of pharyngeal and tonsillar erythema has been used to speculate a link between upper respiratory tract infections and submucosal dissection.1
Esophagoscopy findings of ulceration and extensive hematoma extending submucosally are pathognomic of esophageal apoplexy (Figure B). Treatment is conservative, including fasting, intravenous fluids, and proton pump inhibitors. Prognosis is excellent with recovery within 82 to 23 days.3
References
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
Conflicts of interest The authors disclose no conflicts.
PII: S0016-5085(09)00819-1
doi:10.1053/j.gastro.2009.05.045
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
