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Esophageal hematoma — Clinical Guidelines

Overview

Esophageal hematoma, often secondary to esophageal perforation (e.g., Boerhaave syndrome), is a severe condition characterized by localized bleeding within the esophageal wall leading to hematoma formation, potentially causing mediastinitis and high mortality if not promptly addressed. 1 3 10

Diagnosis

Clinical Presentation: Severe chest pain, dysphagia, fever, and signs of sepsis.

Imaging: Chest CT or esophagography essential for identifying perforation sites and hematoma.

Laboratory Tests: Elevated white blood cell count, inflammatory markers indicative of infection or inflammation.

Endoscopy: Useful for visualizing perforation sites and guiding interventions like endoscopic clipping. 3 13

Management

First-Line Treatments:

- Endoscopic Clipping: Early intervention for sealing perforations (e.g., within 24 hours). 3 - Self-Expandable Metal Stents: Nonoperative endoscopic treatment for benign perforations to manage leakage and promote healing. 6

Surgical Interventions:

- Defunctionalization: Loop cervical esophagostomy and banding for delayed perforations to promote healing. 14 - Laparoscopic or Open Repair: Indicated in cases with sepsis, extensive necrosis, or failure of endoscopic/stent management. 1 17

Supportive Care:

- Antibiotics: To prevent or treat mediastinitis and sepsis. - Fluid Resuscitation: To manage hemodynamic instability. - Nutritional Support: Enteral or parenteral nutrition as needed. 1 10

Special Populations

Elderly: Higher risk of complications; careful consideration of surgical versus endoscopic approaches needed. 1 14

Comorbidities: Presence of comorbidities like sepsis significantly influences management strategy, often favoring surgical intervention. 1 10

Key Recommendations

Early Endoscopic Intervention: For suspected esophageal perforations, early endoscopic clipping or stenting can reduce mortality and morbidity. (Evidence: Moderate 3 6)

Surgical Defunctionalization for Delayed Perforations: In cases where perforation is recognized late, defunctionalization techniques can promote healing and prevent complications. (Evidence: Moderate 14)

Aggressive Supportive Care: Including broad-spectrum antibiotics and hemodynamic stabilization is crucial in managing sepsis and preventing mediastinitis. (Evidence: Moderate 1 10)

References

1 Prosperi P, Alemanno G, Di Bella A, Ardu M, Maltinti G, Iacopini V et al.. A minimally invasive approach with a 3d imaging system for the treatment of esophageal perforation due to Boerhaave syndrome. Annali italiani di chirurgia 2018. link 2 Cameron GR, Jayasekera CS, Williams R, Macrae FA, Desmond PV, Taylor AC. Detection and staging of esophageal cancers within Barrett's esophagus is improved by assessment in specialized Barrett's units. Gastrointestinal endoscopy 2014. link 3 Rokszin R, Simonka Z, Paszt A, Szepes A, Kucsa K, Lazar G. Successful endoscopic clipping in the early treatment of spontaneous esophageal perforation. Surgical laparoscopy, endoscopy & percutaneous techniques 2011. link 4 Mardini S, Salgado CJ, Kim Evans KF, Chen HC. Reconstruction of the esophagus and voice. Plastic and reconstructive surgery 2010. link 5 Weis F, Beiras-Fernandez A, Sadoni S, Hauer D, Nikolaou K, Reichart B et al.. Esophageal perforation after catheterization of the subclavian vein. The heart surgery forum 2008. link 6 Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT. Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. The Annals of thoracic surgery 2006. link 7 Manger T, Pross M, Haeckel C, Lippert H. Malignant peripheral nerve sheath tumor of the esophagus. Digestive surgery 2000. link 8 Lowham AS, Filipi CJ, Hinder RA, Swanstrom LL, Stalter K, dePaula A et al.. Mechanisms and avoidance of esophageal perforation by anesthesia personnel during laparoscopic foregut surgery. Surgical endoscopy 1996. link 9 Gupta NM, Goenka M, Atri A, Singh R. Spontaneous esophageal perforation: atypical presentation. Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology 1995. link 10 Gryga A, Duda M, Dlouhý M, Scheinarová A, Mocnáková M. Mediastinitis due to perforation. Acta Universitatis Palackianae Olomucensis Facultatis Medicae 1994. link 11 Albin J, Noel T, Allan K, Khalil KG. Intrathoracic esophageal perforation with the Angelchik antireflux prosthesis: report of a new complication. Gastrointestinal radiology 1985. link 12 Klausner JM, Epstein L, Peer G, Lelcuck S, Skornick Y, Rozin RR. Perforation of the esophagus (Boerhaave's syndrome) during hemodialysis. Nephron 1985. link 13 Phillips LG, Cunningham J. Esophageal perforation. Radiologic clinics of North America 1984. link 14 Schwartz ML, McQuarrie DG. Surgical management of esophageal perforation. Surgery, gynecology & obstetrics 1980. link 15 Menguy R. On the malignant potential of acquired short esophagus. Archives of surgery (Chicago, Ill. : 1960) 1979. link 16 Clark J, Moraldi A, Moossa AR, Hall AW, DeMeester TR, Skinner DB. Functional evaluation of the interposed colon as an esophageal substitute. Annals of surgery 1976. link 17 Chiang HC, Walstad PM. Modified exclusion technique for complicated esophageal perforation. Chest 1976. link 18 Assor D. A melanocytic tumor of the esophagus. Cancer 1975. link35:5<1438::aid-cncr2820350530>3.0.co;2-q)

Esophageal hematoma