S4451 Esophageal Mass on Upper Endoscopy Following Transesophageal Echocardiography

Introduction: Transesophageal-echocardiography (TEE) is commonly used for detailed cardiac imaging of various cardiac conditions. While generally safe, it can occasionally lead to upper gastrointestinal (GI) adverse events. Here, we present a case of TEE-induced trauma that interestingly, presented as an esophageal mass lesion. Case Description/Methods: An 82-year-old woman with a past medical history of paroxysmal atrial fibrillation on apixaban, coronary and valvular heart disease was evaluated for a 3-day history of melena during a hospitalization for acute heart failure. She denied any dysphagia or prior history of GI bleeding. Her vitals were unremarkable. Physical examination showed pallor but she was otherwise well appearing. She had a TEE 8 days prior to evaluation and her hemoglobin dropped from 8.3 g/dL to 6.0 g/dL in this timeframe. Esophagogastroduodenoscopy (EGD) 1 year prior had shown a hiatal hernia and erosive gastritis. Computed tomography chest, abdomen, pelvis revealed heterogeneity of sternum, thoracic and lumbar spine, suspicious for metastatic disease. The patient received 2 units packed red blood cells, intravenous pantoprazole, and empiric octreotide; her apixaban was held. Due to suspicion of GI bleeding, EGD was performed and revealed a large, friable, ulcerated 13 mm esophageal mass with necrotic debris and blood clots. Small biopsies were obtained. Initial concern was traumatic ulceration of a possible underlying mass secondary to the recent TEE. Given no suspicion for varices, octreotide was discontinued. Biopsies revealed fragments of necrotic ulcer exudate with atypical squamous epithelium—deemed superficial and non-representative. Oncologic workup including SPEP, tumor markers, and nuclear bone scan were unremarkable. Her melena subsequently resolved, and she was managed conservatively with twice daily pantoprazole and close hemoglobin monitoring. Follow-up EGD 2 weeks later showed marked endoscopic improvement, revealing only 2 superficial linear ulcers in the lower third of the esophagus, without evidence of mass or residual hematoma. Discussion: Though initially suggestive of malignancy, the esophageal mass was ultimately attributed to TEE-induced injury. To our literature review, we found 14 cases of TEE-related esophageal hematoma, emphasizing its rarity. Therefore, clinicians should be cautious with invasive instrumentation, particularly in elderly anticoagulated patients.