Dissecting intramural haematoma of the oesophagus

Abstract

Dissecting intramural haematoma of the oesophagus is an under-recognized cause of sudden onset chest pain. Diagnosis is aided by the common co-existence of haematemesis, odynophagia, and dysphagia. Oesophagoscopy, barium swallow and cross-sectional radiology are all appropriate modalities of investigation. The latter is useful in excluding aortic dissection from the differential diagnosis. The condition usually follows a benign course with spontaneous healing requiring supportive treatment only. A systematic analysis of all the cases of dissecting intramural haematoma of the oesophagus (DIHO) reported in the worldwide literature reveals that this is essentially a benign condition. Eighty per cent of patients have at least two of the three typical presenting features of chest pain, haematemesis and dysphagia or odynophagia. Forty-nine per cent of cases are associated with sudden pressure changes within the oesophagus (e.g. due to swallowing) or secondary to direct trauma to the oesophagus. A further group appears to arise spontaneously and may be associated with underlying abnormal pressure changes within the oesophagus or a bleeding tendency. Awareness of the condition prevents the pain being mistakenly attributed to a cardiac cause. With conservative management the symptoms usually resolve within 2 weeks of presentation. The only mortality associated with DIHO is due to operative intervention or where there is another underlying life-threatening condition.