Clinicsal picture
An 82-year-old woman was found unconscious and brought to our hospital in an ambulance. Head computed tomography (CT) was performed, which revealed the diagnosis of subarachnoid hemorrhage. After surgery was performed, the patient was admitted to the intensive care unit. Thereafter, a nasogastric tube insertion was attempted but was found difficult. Thus, a gastric tube insertion using an endoscope was attempted. During endoscope insertion, bleeding in the oral cavity and a hematoma in the right piriform fossa were noted. Chest CT was performed owing to persistent bleeding from the esophageal orifice. Chest CT images via a mediastinal window revealed air circumferentially infiltrating the esophageal wall and extending up to the gastroesophageal junction (Figure 1A). The same site clearly depicted air in the esophageal wall when examined on CT images through a pulmonary window(Figure 1B). Based on these findings, the patient was diagnosed with iatrogenic intramucosal esophageal dissection. Intramucosal esophageal dissection is a rare disorder and is classified as traumatic, iatrogenic, and idiopathic.1 Endoscopy is considered to be a common iatrogenic cause.2 In case of difficulty in gastric tube insertion, this disorder may occur. Thus, CT should be performed in suspected cases of this disorder to avoid abscess formation.
References
1.Soulellis CA, Hilzenrat N, Levental M. Intramucosal esophageal dissection leading to esophageal perforation: case report and review of the literature. Gastroenterol Hepatol (N Y) 2008; 4: 362-365
2.Young CA, Menias CO, Bhalla S, Prasad SR. CT features of esophageal emergencies. Radiographics 2008; 28: 1541-1553