Intramural esophageal dissection. a case report:

:We present the case of a 21-year-old male patient who came to the emergency department for intermittent chest pain of several days of evolution, associated with progressive epigastralgia, which clearly increased with the intake of solids and liquids. The physical examination was afebrile and hemodynamically stable. Analytically, they highlighted: PCR 112, leukocytosis over 16,500 (85% neutrophils) and D-dimer of 2.8, with hypoxemia and hypocapnia. A thoracic CT angiography was requested, identifying a prevertebral hypodense collection that conditioned compression of the esophagus and displaces it anterolaterally to the right, associating increased fat density in the upper and middle mediastinum. With clinical suspicion of superinfected esophageal duplication cyst versus retroesophageal collection secondary to microperforation, with incipient mediastinitis, urgent upper gastrointestinal endoscopy was performed in the operating room under anesthetic control. The findings were hemorrhagic subfusions of ischemic appearance in the esophageal mucosa with mild protrusion towards the light, visualizing two small aligned holes where bubbling was observed and through which spontaneously cloudy fluid was draining. In light of these findings the surgical team performed right lateral thoracotomy, revealing turbid pleural fluid and inflammatory changes in the posterior mediastinum, placing one paraesophageal drainage catheter and two at pleural level (anterior apical and posterior basal).

The spontaneous intramucosal esophageal dissection was first described in 1968 and since then, more than 50 cases have been reported, generally accepting that the most common causes of this entity are iatrogenic. It is an unusual clinical entity, characterized by a long laceration between the mucosa and submucosa of the esophageal wall of the deeper muscular layers due to abrupt increases in the intraesophageal pressure. We must emphasize the anticoagulation as a risk factor for the development of a spontaneous dissection causing a primary hemorrhage within the submucosa which may be responsible for the separation of the layers.

It is a condition considered to be relatively benign but that has the potential to lead to a perforation. Currently most of these cases of spontaneous dissection can be treated conservatively but always maintaining a high suspicion of perforation, in which a more aggressive treatment with surgical intervention should be applied. In these cases anaccurate diagnosis will be necessary through optimal imaging techniques that include contrast esophagogram and contrast-enhanced CT of the esophagus, where significant extravasation of contrast will be observed outside the lumen.

- Soulellis CA, Hilzenrat N, Levental M. Intramucosal esophageal dissection leading to esophageal perforation: case report and review of the literature. Gastroenterol Hepatol 2008,4(5):362-5. - Zhou B, Tan Y, lv L, Liu D. Dysphagia and hematemesis caused