A Rare Cause for Acute Chest Pain in the Emergency Setting That Is Hard to Swallow

Intramural esophageal hematoma is a very rare but important cause of chest pain. This condition shares similarity with the diagnosis of other thoracic emergencies and has a high potential for misdiagnosis. The emergency clinician plays a critical role in the early identification and management of these patients. The management of intramural hematomas is typically conservative, and a misdiagnosis could lead to deleterious effects. Preexisting coagulopathy is one of the major risk factors. With the advent of new anticoagulation medications to prevent thromboembolic events, it is important that emergency medicine providers expand the differential diagnosis of chest pain. 1. Introduction An intramural esophageal hematoma (IEH), also described as incomplete Boerhaave’s syndrome, intramural dissection, or intramural hemorrhage, is a rare condition. The presenting symptoms are nonspecific but may include chest pain, back pain, dysphagia, hematemesis, or globus hystericus. Because it can be associated with esophageal perforation, IEH should be considered in emergency department patients with retrosternal chest pain, dysphagia, hematemesis, and odynophagia [1]. We present a case of substernal chest pain in a patient anticoagulated with dabigatran who was initially diagnosed with a distal esophageal impaction but instead had this rare condition. Lastly, we perform an in-depth review of the literature and case reports regarding evaluation and management of intramural esophageal hematomas. 2. Case Presentation An 81-year-old female with a past medical history significant for atrial fibrillation status post recent cardiac ablation on dabigatran (Pradaxa, Boehringer Ingelheim Pharm) presented to a local emergency department (ED) for evaluation of chest pain that started immediately after drinking juice. The pain was described as similar to previous episodes, but when the pain did not remit, she went to her local ED. An electrocardiogram (EKG) and laboratory studies were obtained, which were significant for normal sinus rhythm without ST changes and a hemoglobin of 13.9？g/dL (8.63？mmol/L; range: 12.0–16.0？g/dL; 7.4–9.9？mmol/L) [2]. Due to concern for an aortic aneurysm, computed tomography angiography (CTA) was performed which demonstrated a distal impaction of her esophagus, with greatest suspicion for impacted food bolus. The patient was transported to our tertiary care ED for a gastroenterology consult and endoscopy. On arrival to the tertiary care ED, the patient was hemodynamically stable. Cardiac, respiratory, and abdominal examinations were unremarkable.