CASE REPORT

We report the case of a 60-year-old male with aggravated dysphagia and hematemesis after ingesting coarse food. Computed tomography identified a dissected esophagus with a thickened wall. Scattered esophageal mucosa defects with the muscularis propria layer exposed were found by endoscopy. In addition, there were two "submucosal tunnels" that connected three major neighboring defects (Fig. 1). Endoscopic ultrasonography identified a lack of the mucosa and submucosa muscular layer of the lesions, while the muscularis propria and external coat were clear (Fig. 2). The length of the whole abnormal segment was 20 cm. The final diagnosis was intramural esophageal dissection. The case was treated conservatively for two weeks but there was no improvement. Subsequently, a covered metal stent was implanted which significantly relieved the dysphagia. The patient was discharged and has not suffered a recurrent dysphagia or hematemesis during a follow-up of six months.

Fig. 1 A. Esophageal mucosa defects at 20 cm from the incisors, which is the entrance of the first "submucosal tunnel". B. The first "submucosal tunnel" at 24 cm from the incisors. C. Exit of the first tunnel at 25 cm from incisors, which is also the entrance to the second tunnel. D. The second "submucosal tunnel" at 27 cm from the incisors. E. End of the second "submucosal tunnel" at 30 cm from the incisors. 

Fig. 2 The lack of mucosa and submucosa muscular layer of the lesions via ultrasound endoscopy. 

DISCUSSION

Intramucosal esophageal dissection is a rare disease characterized by a lengthy laceration between the mucosal and submucosal layers of the esophageal wall without perforation ¹. Forceful vomiting, mechanical insult and an underlying coagulopathy are common causes. The dissection is usually partial, while spontaneous circumferential dissection is rare. Conservative management is currently recommended ¹. However, in this particular case the dissections were too severe to be managed conservatively and the implantation of a covered metal stent resolved the condition. In conclusion, covered metal stent could be the treatment choice for spontaneous intramucosal esophageal dissection including circumferential dissections.