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