A 71-year-old woman with primary myelofibrosis and esophageal varices was admitted
for her first rubber band ligation procedure (platelet count, 58 000/mm3; partial thromboplastin time, 33.4 seconds; international normalized ratio, 1.28).
At endoscopy, the esophageal mucosa was extremely fragile and difficult to aspirate
into the ligation device. Three of the six rubber bands placed at the gastroesophageal
junction slipped off, leaving oozing blood. This was treated by injecting 3.5 mL of
polidocanol (Aethoxysklerol; Base Pharma, Gordon, NSW, Australia). During withdrawal
of the endoscope, several areas with bluish bullous lesions (each < 1 cm in diameter)
were observed in the upper two-thirds of the esophagus ([Fig. 1]). One of these lesions, which showed slight oozing of blood, was injected with 1 mL
of polidocanol.
Fig. 1 After an endoscopic ligation procedure for esophageal varices, small bluish lesions
are observed during withdrawal of the endoscope.
Hematemesis developed 4 hours later, with a drop in the hemoglobin concentration of
0.8 g/dL to 10.2 g/dL. At second-look endoscopy, the submucosal bullae involved up
to half of the circumference of the esophagus and more than two-thirds of its length
([Fig. 2 a, b]). One of these bullae had ruptured and was covered by a clot ([Fig. 2 c]). The rubber bands were still in place. There was no ongoing bleeding. Within the
next 18 hours, the hemoglobin concentration decreased to 7.6 g/dL, and the patient
received two thrombocyte concentrates. At follow-up endoscopy after 6 weeks, the mucosa
of the upper two-thirds of the esophagus was normal ([Fig. 3]). Varices were still present in the lowest third.
Fig. 2 a, b At second-look endoscopy, the bullous lesions have expanded. c A blood clot covers a ruptured bulla (to the left of the bulla).
Fig. 3 Follow-up endoscopy after 6 weeks.
Intramural hematoma of the esophagus is a rare entity [1]. It may occur spontaneously; be secondary to a coagulopathy, as in myelofibrosis
[2]; or develop after variceal sclerotherapy [3]. In our patient, low platelet counts, abnormal platelet function, sclerosis of the
esophageal mucosa, and sclerotherapy may have been contributing factors. In summary,
intramural hematoma of the esophagus is a rare complication that can result in severe
blood loss. However, the prognosis is good with conservative management [4].
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AG
