Spontaneous intramural oesophageal dissection.

Abstract

Spontaneous intramural dissection oftheoesphagus isa rare condition. Inthis report wedescribe apatient withthis lesion whowasmanagedsuccessfully without operation. Aswellasdemonstrating thecharacteristic radiographic andendoscopic features, ourcasesuggests that theingestionofsolid unmasticated foodmaybeanimportant aetiological feature that hasnotbeenemphasised inpreviouspublications. Casereport A 70 yearoldedentulous womanpresented asan emergency, complaining ofacuteonsetofsevereand worsening retrosternal pain. Atlunchtime onthat dayshe hadeaten quickly apiece oflamb. Shefelt thefoodstick at thelevel ofhermanubrium andwithin afewminutes developed chest painradiating fromthemanubrium tothe epigastrium. Shethenvomited-initially clear fluid, followedbybright redbloodinincreasing quantities. Swallowing wasnoticed toexacerbate thepain. Finally the offending piece oflambwasvomited. On examination thetrachea wastender tomovement, butthere wasnosurgical emphysema. Chestradiography andauscultation ofthechest showednoabnormality. Abdominal examination also showed nothing abnormal. A barium swallow donetwohours after admission showed a double barrelled appearance (figure). Endoscopy, performed thesameevening, showedamucosal tearposteriorly 15cm fromthealveolar margin, andfromthis lesion there wasabluish column that extended downtothe oesophagogastric junction andlooked rather like asingle longoesophageal varix. Administration ofintravenous fluids andparenteral broadspectrum antibiotics wasstarted andthepatient was allowednothing by mouth.After48 hoursthe odynophagia hassubsided andatseven days, after arepeat barium swallow, oral fluids werecommenced, followed by return toanormal diet. Thepatient left hospital after 10 days andatreview onemonthlater wassymptom free, with nodysphagia orodynophagia.