Spontaneous esophageal hematoma

FATAL GASTRODUODENAL ARTERY BLEEDING

An 85-year-old woman was brought to the emergency room after several episodes of ‘‘coffeeground’’ emesis. The initial hematocrit was 27% (normal: 40-45%). A few hours after resuscitation, frank blood began to flow rapidly from a nasogastric tube, and the clinical condition of the patient became unstable, necessitating endotracheal intubation and blood transfusions. EGD revealed large volumes of fresh blood in the stomach and a 5-cm diameter

duodenal ulcer with an actively bleeding vessel. Attempts to stop the bleeding by injections of a solution of epinephrine failed, and the patient again became hemodynamically unstable. After further resuscitation by infusion of crystalloid and blood products, the patient underwent emergency surgery. A large, actively bleeding vessel just distal to the pylorus was suture ligated, and the bleeding ceased. Vagotomy and pyloroplasty were performed. However, the vicious cycle of hypothermia, coagulopathy, and acidosis developed after surgery, and, despite all supportive measures, the patient succumbed. At autopsy, gross inspection of the duodenum revealed a 5-cm diameter ulcer (block arrows). Embedded within the crater, the eroded gastroduodenal artery (large arrow) was clearly visible. Hernan A. Bazan, MD Unsup Kim, MD Mount Sinai School of Medicine Elmhurst Hospital Center Elmhurst, New York PII:S0016-5107(03)02109-6

SPONTANEOUS ESOPHAGEAL HEMATOMA An 80-year-old woman with stable angina pectoris was admitted to the coronary care unit because of the acute onset of retrosternal pain. The pain was described as cramping and had begun 3 hours after dinner. The patient was taking aspirin (80 mg) daily. Examination and standard laboratory tests, including coagulation parameters, were within normal ranges. An electrocardiogram revealed no evidence of ischemia. Hematemesis developed a few hours after admission, and an EGD was performed. In the esophagus, from 23 to 40 cm, a blue-colored mass was bulging into the lumen and occupied over a half of the circumference (A). Except for a blood clot at the gastroesophageal junction, no focus of active bleeding was detected. Magnetic resonance imaging and magnetic resonance angiography demonstrated an intramural mass in the esophageal wall (B, VOLUME 58, NO. 5, 2003

GASTROINTESTINAL ENDOSCOPY

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At the Focal Point...

arrow). A diagnosis of spontaneous esophageal intramural hematoma was made, and the use of aspirin was stopped. Treatment was initiated with omeprazole (40 mg twice a day) and a liquid diet (for 3 days). After 10 days, the patient was discharged free of symptoms. At endoscopy 6 weeks later, the esophagus was normal in appearance, indicating complete regression of the hematoma. Treatment with aspirin was resumed without complication. B. W. Marcel Spanier, MD Marco J. Bruno, MD, PhD Jan L. Meijer, MD, PhD Academic Medical Center University of Amsterdam Amsterdam, The Netherlands Spaarne Ziekenhuis Heemstede Heemstede, The Netherlands PII:S0016-5107(03)02004-2

KLIPPEL-TRENAUNAY-WEBER SYNDROME AND DUODENAL HEMORRHAGE

A 61-year-old Japanese woman with KlippelTre´naunay-Weber syndrome was hospitalized because of melena and hematemesis. Examination disclosed marked generalized pallor, diffuse hypertrophy of the right leg (A), and hemihypertrophy of the right external genitalia. Hypoplasia of the portal vein was demonstrated by CT. An ulcer with an 756

GASTROINTESTINAL ENDOSCOPY

exposed vessel in the crater was found in the descending duodenum at endoscopy (B). The ulcer had the VOLUME 58, NO. 5, 2003