Answer
From question on page 814
On endoscopy, there was a dark purplish bulging mucosa over the mid‐to‐distal oesophagus with a linear mucosal ulceration around it. Chest CT scan disclosed a hyperdense long segmental submucosal lesion extending from the carina to the oesophageal–gastric junction (figs 2 and 3, arrows). The diagnosis was oesophageal intramural haematoma (EIH).
EIH is a rare form of oesophageal injury. Patients usually present with a sudden onset of retrosternal chest pain, back pain, haematemesis, dysphagia or odynophagia. The disorder can occur spontaneously following forceful vomiting, or it can be secondary to variceal injection therapy, oesophageal dilatation, food impaction, improper swallowing of tablets or coagulopathy. Endoscopically, the lesion is described as a purplish, submucosal mass occupying most of the lumen. CT scan typically shows a hyperdense mass within the oesophageal wall, which aids in the differentiation of the haematoma from aortic dissection or oesophageal rupture. EIH usually carries a good prognosis and most patients have complete resolution of symptoms in 2–3 weeks with conservative treatment. Endoscopic therapy or surgical intervention are reserved for those with worsening symptoms such as airway compression.
A passed fish bone was presumed to have caused EIH in the present case. This patient's symptoms improved after 2 days of conservative treatment, and she resumed oral intake on the 3rd hospital day. She was discharged and had no sequelae in the following year.