eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Hematoma: Differential Diagnoses & Workup

Author: Jennifer Lynn Bonheur, MD, Fellow, Department of Internal Medicine, Division of Gastroenterology, Lenox Hill Hospital
Coauthor(s): Klaus Radebold, MD, PhD, Research Associate, Department of Surgery, Yale University School of Medicine
Contributor Information and Disclosures

Updated: Jul 20, 2006

Differential Diagnoses

Boerhaave Syndrome
Myocardial Infarction
Esophageal Cancer
Pulmonary Embolism
Esophageal Rupture
Esophageal Varices
Mallory-Weiss Tear

Other Problems to Be Considered

Dissection of the thoracic aorta
Aortoesophageal fistula

Workup

Laboratory Studies

  • The laboratory workup should include hemoglobin concentration and coagulation profile with platelet count.
  • Cardiac enzymes and troponin levels should be drawn to exclude a cardiac cause for the patient's chest pain.

Imaging Studies

  • Chest radiograph
    • Chest radiographs may reveal a broadened mediastinal mass or bilateral pleural effusions.
    • Preliminary study helps to exclude a perforation and other pathologies included in the differential diagnosis of chest pain.
  • Barium swallow (esophagram)
    • Typically, this study helps to confirm the diagnosis, revealing a filling defect in the mid and lower esophagus, usually on the posterior wall, with luminal narrowing and sometimes with mucosal irregularity.
    • Extravasation into the mediastinum is not observed unless a perforation has occurred.
    • A double barrel sign or a mucosal stripe sign may be demonstrated, that is, double columns of contrast medium separated by a radiolucent stripe and a large intramural mass that reflects a mucosal dissection that allows extravasation of contrast material into the hematoma.
  • CT scan with contrast
    • CT scan reveals a nonenhancing, eccentric, well-defined, intramural esophageal mass that has the density of blood.
    • CT scan can help to better characterize esophagram findings, accurately define the extent of intramural dissection, and exclude esophageal perforation.
    • CT scan is useful in excluding other conditions that may mimic esophageal hematoma, including mass lesions, aortic dissection, and pulmonary embolism.
  • MRI
    • MRI can help demonstrate the extent of the hematoma in various planes and can help rule out additional mediastinal pathology.
    • MRI is indicated for patients who cannot have a CT scan because of an allergy to iodinated contrast medium or renal impairment.
  • An endoscopic ultrasound (EUS) shows an intramural hypoechoic submucosal mass.

Procedures

  • Upper endoscopy
    • It has been suggested that fiberoptic endoscopy is relatively contraindicated in the further evaluation of esophageal hematoma because many intramural hematomas are contained perforations that could be worsened by the insufflation of air.
    • Others endorse the use of endoscopy in the initial evaluation once esophageal perforation has been ruled out.
    • Endoscopically, an esophageal hematoma is described as a bluish or purplish colored, submucosal mass protruding into the esophageal lumen.
    • Endoscopy can precisely identify the tear in the mucosa, but the risk of the procedure should be weighed against the need for this information and the generally uncomplicated course that these patients follow.

More on Esophageal Hematoma

Overview: Esophageal Hematoma
Differential Diagnoses & Workup: Esophageal Hematoma
Treatment & Medication: Esophageal Hematoma
Follow-up: Esophageal Hematoma
References
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References

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Further Reading

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Keywords

esophageal apoplexy, esophageal mucosal tears, Mallory-Weiss syndrome, transmural perforation, Boerhaave syndrome, intramural hematoma of the esophagus, esophageal perforation, mediastinitis, abscess formation, vomiting, dysphagia, odynophagia, hematemesis, severe acute chest pain

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Contributor Information and Disclosures

Author

Jennifer Lynn Bonheur, MD, Fellow, Department of Internal Medicine, Division of Gastroenterology, Lenox Hill Hospital
Jennifer Lynn Bonheur, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, New York Academy of Sciences, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Klaus Radebold, MD, PhD, Research Associate, Department of Surgery, Yale University School of Medicine
Klaus Radebold, MD, PhD is a member of the following medical societies: American Gastroenterological Association and New York Academy of Sciences
Disclosure: Nothing to disclose.

Medical Editor

Maurice A Cerulli, MD, FACG, Chief, Division of Gastroenterology and Hepatology, Associate Professor of Clinical Medicine, Department of Internal Medicine, Division of Gastroenterology, New York Methodist Hospital, Cornell University
Maurice A Cerulli, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Medical Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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