S4313 Esophageal Hematoma: An Uncommon Case of Acute Dysphagia

Introduction: Esophageal submucosal hematoma is an uncommon condition caused by rupture of submucosal blood vessels. Most cases present with chest pain, vomiting, or dysphagia soon after the inciting cause. Only a small proportion of cases present following a fall in elderly patients. We report the case of a 76-year-old lady who experienced sudden onset neck pain and dysphagia after falling at home while taking apixaban, which mimicked esophageal cancer on imaging. Case Description/Methods: A 76-year-old woman presented to the emergency room with bilateral neck pain and difficulty swallowing. She fell out of her bed onto a carpeted floor around 2 AM while having a nightmare. She did not lose consciousness. Her medical history includes chronic atrial fibrillation on Eliquis and breast cancer status lumpectomy and radiation. On presentation, she was tachypneic, but other vital signs were stable. Her physical exam was unremarkable. The complete blood count was normal. Non-contrasted computed tomography of her cervical spine revealed prominent soft tissue thickening in the cervical and upper esophageal/retrotracheal soft tissue. Possible esophageal wall thickening with intraluminal debris was also noted. Based on the recommendation of the radiologist, a follow-up contrast-enhanced computed tomography chest was done and showed a 4.1 × 4.5 cm marked esophageal prominence with near-complete luminal occlusion in the superior thoracic esophagus. This finding was suspicious for malignancy. She was admitted, placed on intravenous fluids, NPO, pantoprazole, and apixaban was held. The gastroenterology team was consulted, and the patient underwent esophagoduodenoscopy on day 2, which revealed semicircumferential purple discoloration from 27 to 31 cm from the incisors, consistent with a submucosal hematoma. There was no ulcer or mass seen. Dysphagia resolved during hospitalization. She was discharged with instructions to hold apixaban for 2 days. On follow-up few months later, patient's symptoms have completely resolved. Discussion: We have presented the case of a 76-year-old lady on apixaban who presented with dysphagia following a fall at home. This case highlights that esophageal submucosal hematoma can result from minor indirect injuries, and computed tomography scans may not be diagnostic. Physicians should have a high index of suspicion to differentiate hematoma from cancer, especially in the absence of weight loss.