Double-barrelled oesophagus caused by intramural dissection
A 70 year old female presented with a history of dysphagia for solid food, odynophagia and minor haematemesis for at least 2-3 years. In recent months the complaints had worsened significantly with progressive dysphagia, finally even for liquids. An oesophagoscopy was not conclusive and had to be terminated immediately after sudden onset of chest pain.
Chest CT (computed tomography) showed a pneumomediastinum and a "double-barrelled oesophagus", the latter due to air in the oesophageal lumen and air in the wall. These findings suggested a perforation (possibly iatrogenic) of the oesophageal wall.
One week later evaluation of the upper gastrointestinal tract was performed using water soluble contrast material. This examination demonstrated a longitudinally oriented linear filling defect in the oesophagus, extending from the level of the aortic arch to the distal part nearly at the level of the gastro-oesophageal junction, thus creating a double barrel.
The dissected mucosal flap separated the contrast-filled true lumen, characterised by the presence of tertiary contractions, from the intramural space, which was opacified by a minimal amount of contrast material. There was no evidence of leakage of contrast material into the mediastinum.
Possible differential diagnoses were intramural abscess or diverticulum and oesophageal duplication.
Spontaneous resolution of the findings can rule out these entities.
The description of a "double-barrelled oesophagus" refers to the radiographic appearance of an intramural dissecting channel that is separated from the normal oesophageal lumen by an intervening lucent stripe, represented by the mucosa. This pattern strikingly simulates the findings in a dissecting aortic aneurysm.
The dissection is probably produced by an intramural haematoma secondary to severe vomiting, trauma, instrumentation or ingestion of foreign bodies. The intramural haematoma can also be seen in cases of bleeding diathesis (primary disease or as a complication of anticoagulant therapy). Haematoma not related to any definable cause has also been reported.
The occurrence of an oesophageal dissection due to oesophagoscopy is not well documented in the literature. However, the incidence of an oesophageal perforation during oesophagoscopy has been estimated at 0.25%, with a mortality rate of 0.06%.
The triad of haematemesis, odynophagia and dysphagia aids the diagnosis. Sudden onset of chest pain may be an accompanying symptom. These symptoms may mimic spontaneous rupture of the oesophagus, aortic dissection or myocardial infarction. Hence, early accurate diagnosis is vital for appropriate management. The appearance of the oesophagus on contrast studies and on chest CT is characteristic.
Conservative management is thought to be adequate in most cases, with resolution of symptoms within 2 weeks of presentation. However, one case has been described without adequate response to conservative therapy. An endoscopic incision of the septum between the true and false lumens was performed safely and effectively using a needle-type diathermy knife.