Nasogastric Tubes Can Cause Intramural Hematoma of the Esophagus

Abstract

BACKGROUND Intramural hematoma of the esophagus (IHE), a rare manifestation of acute mucosal injuries of the esophagus, can be caused by trauma such as endoscopic surgeries. Coagulation disorders increase the risk of IHE. The most common location of IHE is in the distal esophagus. The characteristic clinical triad of manifestations comprises acute retrosternal pain, odynophagia or dysphagia, and hematemesis. It is important to distinguish IHE from other acute conditions such as acute coronary syndrome, aortic dissection, and pulmonary embolism. CASE REPORT An 84-year-old male was scheduled for coil embolization for an endoleak after endovascular aneurysm repair. For this reason, he was taking aspirin and warfarin. A nasogastric tube had been inserted during surgery and subsequently removed without any problems reported. Postoperatively, he experienced chest pain and hematemesis of sudden onset. Urgent esophagogastroduodenoscopy demonstrated a large, dark red, non-pulsatile, submucosal, esophageal mass in the area of the mid-esophagus with a little oozing. He was diagnosed as having an IHE; other possible diagnoses were excluded by contrast-enhanced computed tomography and aortography. He was treated with fasting, a proton pump inhibitor, and cessation of anti-thrombotic drugs; he recovered completely. The bleeding spot in the esophagus was in the area of the mid-esophagus, which was around the second natural constriction site. It was possible that the nasogastric tube had contact with the esophageal wall at this second natural constriction, and caused intramural esophageal bleeding. CONCLUSIONS Nasogastric tubes are not generally recognized as a cause of IHE. However, they can cause them, especially when a patient is taking anti-thrombotic drugs.

Figure 1.

Contrast-enhanced computed tomography image of esophagus. Horizontal arrow shows diffuse thickening of esophageal wall and luminal narrowing.

Figure 2.

Endoscopic image of the intramural hematoma in the esophagus shows a large, dark red, non-pulsatile, submucosal mass that extended from dental arch 35 cm to 20 cm.

Figure 3.

Endoscopic ultrasonography image of the esophagus. The arrow shows a homogenous hypoechoic lesion in the submucosal layer that was diagnosed as an intramural hematoma.

Figure 4.

Image from endoscopy performed 1 week after development of the intramural hematoma of the esophagus. It shows the submucosal mass has ruptured, exposing submucosal tissue. The vertical arrow indicates a small dark spot in the area of the mid-esophagus (28 cm from dental arch) that may have been the bleeding point; however, it is not actively bleeding.