Disappearing Dysphagia and the Spontaneous Intraesophageal Hematoma

A 73-year-old woman with atrial fibrillation, on rivaroxaban, presented with a 3-day history of acute dysphagia. Chest computed tomography (CT) showed an esophageal mass (Figure 1). Esophagogastroduodenoscopy revealed severe extrinsic esophageal stenosis (Figure 2). Endoscopic ultrasound-guided biopsy resulted in necroinflammatory debris. At this time, her symptoms of dysphagia began to improve. Repeat chest CT surprisingly showed the mass had disappeared. Instead, a new pre-esophageal lumen was seen (Figure 3). Repeat esophagogastroduodenoscopy discovered a small mucosal defect in the location of the previously biopsied mass (Figure 4). CT esophagram was performed without extravasation of contrast into the false lumen (Figure 5). Chest CT angiography was ordered and revealed a blush of contrast from a midesophageal artery (Figure 6). Interventional radiology performed a selective thoracic angiogram that revealed a small intercostal artery demonstrating an arterial blush, without signs of active bleeding. No further intervention was performed. Intramural esophageal hematoma is an unusual esophageal injury and a rare diagnosis for dysphagia.1 Intramural esophageal hematoma is commonly seen following blunt and penetrating trauma or as a complication of an endoscopic procedure.2 Spontaneous hematomas are those that lack a precipitating event and commonly occur in patients on anticoagulation.3Figure 1.: Chest computed tomography with mediastinal mass causing dysphagia.Figure 2.: Esophagogastroduodenoscopy with severe esophageal stenosis from extrinsic compression.Figure 3.: Repeat chest computed tomography with resolution of the mass and pre-esophageal lumen.Figure 4.: Repeat esophagogastroduodenoscopy with esophageal defect.Figure 5.: Computed tomography esophagram without extravasation of contrast into false lumen.Figure 6.: Chest computed tomography angiography with arterial blush of contrast.DISCLOSURES Author contributions: A. Wayne Wheeler: primary author and contributor and is the article guarantor; S. Landreneau: contributing author, editor, and reviewed case for poster submission and case publication. Financial disclosure: None to report. Previous presentation: Previously presented at the ACG Annual Scientific Meeting; October 20–25, 2023; Vancouver, BC, Canada. Informed consent was obtained for this case report.

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