Esophageal intramural pseudodiverticulosis

Esophageal intramural pseudodiverticulosis(EIPD)is a disease of unknown pathogenesis characterized by usually systemic,cystic dilatation of the excretory ducts of esophageal submucosal glands.In this article,I review the epidemiology,clinical manifestations,endoscopic findings,esophagographic findings,and histopathology of EIPD.I also discuss the etiology and possible pathogenesis of EIPD based on my experiences with this disease and a review of the literature.EIPD usually presents with dysphagia in middle-aged individuals.It is often complicated with secondary infections,most commonly candidiasis.On esophagography,EIPD is delineated as small,multiple,flask-shaped outward projections within the esophageal wall.In recent years,EIPD has been mainly diagnosed by endoscopic findings of multiple,localized,small mucosal depressions.The orifices of the“pseudodiverticula”periodically open and close,and excrete mucus onto the mucosal surface.On histopathological examination,the luminal surface of dilated ducts in EIPD is covered by multilayered,hyperplastic epithelial cells,but myoepithelial cells in the glandular acini are well preserved.Treatment of EIPD is usually symptomatic therapy,and prevention of the infectious complications is important.The etiology and pathogenesis of EIPD are largely unknown,but functional abnormalities of autonomic nerve fibers innervating the esophageal glands likely play an important role,since the structures of the glands are basically preserved in this disease.

Achalasia combined with esophageal intramural hematoma:Case report and literature review

A 62-year-old male patient was admitted to our hospital due to severe chest pain,odynophagia,and hematemesis.Chest computed tomography showed an esophageal submucosal tumor.Esophagogastroduodenoscopy(EGD) revealed a longitudinal purplish bulging tumor of the esophagus.Endoscopic ultrasound(EUS) showed a mixed echoic tumor with partial liquefaction from the submucosal layer.The patient was diagnosed with esophageal intramural hematoma as well as achalasia by upper gastrointestinal endoscopy,esophagography and esophageal manometry.The patient was managed conservatively with intravenous nutrition,and oral feeding was discontinued.Follow-up EGD and EUS showed complete recovery of the esophageal wall,and finally,the patient underwent endoscopic dilatation for achalasia.The patient was symptom free at the time when we wrote this manuscript.

Acute pancreatitis secondary to intramural duodenal hematoma:Case report and literature review

Nontraumatic intramural duodenal hematoma(IDH) is rare disease and it is generally related to coagulation abnormalities.Reports of nontraumatic IDH associated with pancreatic disease are relatively rare,and various conditions including acute or chronic pancreatitis are thought to be associated with nontraumatic IDH.However,the association between IDH and acute pancreatitis remains unknown.We report the case of a 45-year-old man who presented with vomiting and right hypochondrial pain.He had no medical history,but was a heavy drinker.The diagnosis of IDH was established by computed tomography,ultrasonography and endoscopy,and it was complicated by acute pancreatitis.The lesions resolved with conservative management.We discuss this case in the context of previously reported cases of IDH concomitant with acute pancreatitis.In our patient,acute pancreatitis occurred concurrently with hematoma,probably due to obstruction of the duodenal papilla,or compression of the pancreas caused by the hematoma.The present analysis of the published cases of IDH with acute pancreatitis provides some information on the pathogenesis of IDH and its relationship with acute pancreatitis.

Esophageal intramural pseudodiverticulosis of the residual esophagus after esophagectomy for esophageal cancer

A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer(T3N2M0 Stage Ⅲ) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation,including redness,erosion,edema,bleeding,friability,and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine,gastrografinfilled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly,endoscopic balloon dilatation was performed and antifungal therapy was started in the hospital. Seven weeks later,endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently,the patient was discharged. At the latest follow-up,the patient was symptomfree and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.

Intramural pregnancy after in vitro fertilization and embryo transfer:A case report

BACKGROUND Intramural pregnancy is a rare type of ectopic pregnancy,which is diagnosed by transvaginal ultrasound and magnetic resonance imaging.Management strategies vary depending on the site of the pregnancy,the gestational age and the desire to maintain fertility.The incidence of intramural pregnancy in assisted reproductive technology is higher than that in natural pregnancy.CASE SUMMARY We present a case of intramural pregnancy after in vitro fertilization and elective single embryo transfer following salpingectomy.The patient was completely asymptomatic and her serumβ-human chorionic gonadotropin level increased from 290 m IU/m L to 1759 m IU/m L.Three-dimensional transvaginal ultrasound indicated a heterogeneous echogenic mass arising from the uterine fundus which was surrounded by myometrium and a slender and extremely hypoechoic area stretching to the uterine cavity which was thought to be a fistulous tract.Therefore,we considered a diagnosis of intramural pregnancy and laparoscopic surgery was conducted at 7 wk gestation.CONCLUSION Early diagnosis and treatment of intramural pregnancy is significant for maintaining fertility.

Clinical medical decision-making of acute aortic intramural hematoma: A non-randomized retrospective case study

Objective:This study explored the timing of interventional treatment for acute intramural aortic hematoma(IMH)and the corresponding high-risk factors for its development into local aortic dissection(AD).Method:This retrospective case study method examined clinical follow-up data of 42 patients with acute IMH between April 2013 and October 2016 from the First Affiliated Hospital of Xi?an Jiaotong University.SPSS 17.0 and PPMS1.5 were used to analyze follow-up data spanning 3–12 months(mean,7.5?3.7 months).Results:Patients were divided into the conversion group and the hematoma group according to whether they developed AD.Among them,16 patients(38.1%)developed AD and were treated with thoracic endovascular aortic repair(TEVAR).The remaining patients(61.89%)were treated conservatively.After 1 week,the mean aortic diameter of the conversion versus hematoma group was significantly widened.Hemodynamically unstable patients and those with hematoma to the abdominal aorta extension were more likely to develop AD.Patient outcomes after TEVAR were similar between groups.Conclusion:Our findings suggest that aortic isthmus diameter!3.0 cm,hematoma extending to the abdominal aorta,and hemodynamic instability are associated with AD development in acute IMH patents.TEVAR should be considered if hematoma thickening,calcification ingression,ulcer progression,or contrast enhancement within the intramural hematoma is noted beyond 2 weeks after IMH onset.

Misdiagnosed Aortic Intramural Hematoma and the Role of Intravascular Ultrasound Imaging in Detection of Acute Aortic Syndrome:A Case Report

Acute aortic syndrome includes classic aortic dissection,aortic intramural hematoma,and penetrating atherosclerotic ulcer– a group of conditions that are defined by their dynamic evolution and similar clinical manifestation.Accurate diagnosis and prompt treatment are essential as all the aforementioned conditions are a signifi cant threat to a patient’s life.However,acute aortic syndrome and especially aortic intramural hematoma may be challenging diagnostic problems.Intravascular ultrasound imaging is a diagnostic method that can be useful for more thorough evaluation of the aortic lesion and can particularly aid in discerning the different forms of acute aortic syndrome.We present a case of a patient with aortic intramural hematoma that was missed by conventional imaging studies but was successfully visualized with intravascular ultrasound imaging.

The potential value of intravascular ultrasound imaging in diagnosis of aortic intramural hematoma

Objective To evaluate the potential value of intravascular ultrasound(IVUS)imaging in the diagnosis of aortic intramural hematoma(AIH).Methods From September 2002 to May 2005,a consecutive series of 15 patients with suspected aortic dissection(AD)underwent both IVUS imaging and spiral computed tomography(CT).Six patients diagnosed as acute type B AIH by CT or IVUS composed the present study group.Results The study group consisted of five males and one female with mean age of 66 years old.All of them had chest or back pain.In one patient,CT omitted a localized AIH and an associated penetrating atherosclerotic ulcer(PAU),which were detected by IVUS.In another patient,CT mistaken a partly thrombosed false lumen as an AIH,whereas IVUS detected a subtle intimal tear and slow moving blood in the false lumen.In the four rest patients,both CT and IVUS made the diagnosis of AIH,however,IVUS detected three PAUs in three of them,only one of them was also detected by CT,and two of them escaped initial CT and were confirmed by follow up CT or magnetic resonance imaging.Conclusions IVUS imaging is a safe examination and has high accuracy in the diagnosis of AIH,particularly for diagnosing localized AIH,distinguishing AIH with thrombosed classic AD and detecting accompanied small PAUs.

Focal intramural hematoma as a potential pitfall for iatrogenic aortic dissection during subclavian artery stenting: A case report

BACKGROUND Iatrogenic aortic dissection(IAD)is a rare but fatal complication of interventional treatment for the proximal supra-aortic large vessels.Several cases of IAD after endovascular treatment of subclavian artery have been reported.Nevertheless,the pathogenesis of IAD is still unclear.Here we report a patient with IAD following a balloon expandable stent implanted into the left subclavian artery(LSA).CASE SUMMARY An 84-year-old man with a history of hypertension was admitted to the Neurology Department of our hospital complaining of dizziness and gait disturbance for more than 1 mo.Computed tomography angiography of the head and neck showed severe stenosis at the proximal LSA and the origin of the left vertebral artery.Magnetic resonance diffusion-weighted imaging of the brain revealed subacute infarctions in cerebellum,occipital lobe and medulla oblongata.He suffered a Stanford type B aortic dissection after the proximal LSA angioplasty with a balloon expandable stent.Thoracic endovascular aortic repair was performed immediately with the chimney technique and he was discharged 20 d later.After exploring the pathogenesis with multimodal imaging analysis,an easily neglected focal intramural hematoma(IMH)in the aorta near the junction of the LSA was found to be the main cause of the IAD.The risk of IAD should be sufficiently evaluated according to the characteristics of aortic arch lesions before the proximal LSA angioplasty.CONCLUSION Focal aortic IMH is a potential risk factor for IAD during a seemingly simple stenting of the proximal LSA.

Submucosal esophageal abscess evolving into intramural submucosal dissection:A case report

BACKGROUND Here we report a rare case of submucosal esophageal abscess evolving into intramural submucosal dissection.CASE SUMMARY An 80-year-old woman was admitted to our emergency department with a chief complaint of dysphagia and fever.Laboratory tests showed mild leukocytosis and elevated C-reactive protein level.Computed tomography showed thickening of the esophageal wall.Upper endoscopy showed a laceration of the esophageal mucosa and a submucosal mass.Spontaneous drainage occurred,and we could see purulent exudate from the crevasse.We closed the laceration with endoscopic clips.The patient did not remember swallowing a foreign body;however,she ate crabs before the symptoms occurred.We prescribed the patient with antibiotic,and the symptoms were gradually relieved.Two months later,upper endoscopy showed that the laceration was healed,and the submucosal abscess disappeared.However,intramural esophageal dissection was formed.We performed endoscopic incision of the septum using dual-knife effectively.CONCLUSION In conclusion,we are the first to report the case of esophageal submucosal abscess evolving into intramural esophageal dissection.The significance of this case lies in clear presentation of the evolution process between two disorders.In addition,we recommend that endoscopic incision be considered as one of the routine therapeutic modalities of intramural esophageal dissection.

Endovascular treatment of traumatic renal artery pseudoaneurysm with a Stanford type A intramural haematoma:A case report

BACKGROUND Aortic intramural hematoma(IMH) associated with aortic branch tear and intramurally located pseudoaneurysm after blunt trauma has not been reported.Here,we report a case of progressive type A aortic IMH associated with a pseudoaneurysm arising from the injured proximal renal artery after blunt trauma.CASE SUMMARY During logging operations,a 66-year-old man experienced blunt force trauma after being injured by a fallen tree.He arrived at our trauma center with a left flank pain complaint.Computed tomography(CT) revealed a pseudoaneurysm arising from the proximal renal artery(localized within the aortic media) and Stanford type A IMH.A covered stent was deployed along the left main renal artery,bridging the pseudoaneurysm and covering the parent artery,successfully excluding the pseudoaneurysm as confirmed using aortography.However,although the degree of the pseudoaneurysm decreased,follow-up CT revealed remnant pseudoaneurysm,likely caused by an endoleak.Subsequently,a covered stent was additionally installed through the previously deployed covered stent.Successful exclusion of the pseudoaneurysm was confirmed using final aortography.In the 7-mo follow-up CT scan,the IMH and pseudoaneurysm completely disappeared with no evidence of stent-related complications.CONCLUSION Endovascular treatment such as stent-graft placement can be an effective and safe treatment for traumatic renal artery injury.

Double Compression of Left Atrium and Pulmonary Artery by a Huge Descending Aortic Aneurysm with Intramural Hematoma Mimicking Pulmonary Embolism: A Case Report

Hemodynamic instability secondary to left atrial (LA) compression by an aortic aneurysm is a rare entity. We report?the case of a 43-year old woman with no previous diagnosis of congestive heart failure who was admitted for an initial diagnosis of pulmonary embolism (PE) based on shortness of breath, hypotension and D-Dimers?elevation. The electrocardiogram and blood counts were within normal limits. The chest X-ray revealed widening of the mediastinum. Transthoracic echocardiography demonstrated LA compression by a large descending thoracic aortic aneurysm. Left and right ventricle systolic functions were preserved. Chest angiography showed LA and left pulmonary artery (LPA) compression by a descending aortic aneurysm and an intramural hematoma with no evidence of PE evidence. Emergency surgery could not be done because of her financial status. She was treated medically and was discharged 1?week later with significant improvement. However she remained hypotensive.

Spontaneous esophageal intramural hematoma in a young man wrongly diagnosed as achalasia

Intramural hematoma of the esophagus is a rare but well described type of acute injury of the esophageal wall and it is more frequently being recognized throughout the world. Patients usually present with acute retrosternal or epigastric pain, minor hematemesis and dysphagia. The condition is mostly seen in women with abnormal coagulation and it can either occur spontaneous or induced by trauma or transesopha-geal procedures. It is associated with food impaction and vomiting. Esophageal intramural hematoma has also been reported in young and healthy patients. Case reports with coexisting achalasia are limited. Management is conservative and its course is benign.

Intramural cardiac hydatid cyst—Incidental finding

Hydatid cyst was commonly found in the liver followed by lungs and brain. Cardiac hydatid cysts are less common compared to hepatic ones. We report a case of intramural hydatid cyst that is incidentally found during the work-up of a hepatic hydated cyst.

A comprehensive review and outlook on risk factors of type A aortic intramural hematoma

Background:Type A aortic intramural hematoma(IMH)is characterized by aortic lesions involving the ascending aorta and aortic arch,with no detectable intimal tear on imaging,no true or false lumen,and no direct communication between the hematoma and the vascular lumen.The typical pathological changes present as annular or crescent-shaped thickening of the ascending aortic wall.Due to the substantially higher risk associated with Type A IMH compared to Type B IMH,treatment approaches vary across countries and medical centers,with the primary treatment strategies being closely related to surgical interventions.Previous risk factors for Type A IMH mainly focused on aortic diameter and hematoma thickness;however,our research group is the first to consider hematoma volume as a risk factor.This article provides a comprehensive review of Type A IMH and an outlook on its risk factors.

Clinical profiles and outcomes of acute type A aortic dissection and intramural hematoma in the current era: lessons from the first registry of aortic dissection in China

Background::Acute type A aortic dissection(ATAAD)and acute type A intramural hematoma(ATAIMH)are life-threatening diseases with high mortality.To better understand their clinical features in the Chinese population,we analyzed the data from the first Registry of Aortic Dissection in China(Sino-RAD)to promote the understanding and management of the diseases.Methods::All patients with ATAAD and ATAIMH enrolled in Sino-RAD from January 1,2012 to December 31,2016 were involved.The data of patients’selection,history,symptoms,management,outcomes,and postoperation complications were analyzed in the study.The continuous variables were compared using the Student’s t test for normal distributions and the Mann-Whitney U test for non-normal distributions.Categorical variables were compared using the Chi-square test or Fisher exact test.Results::A total of 1582 patients with ATAAD and 130 patients with ATAIMH were included.The mean age of all patients was 48.4 years.Patients with ATAAD were significantly younger than patients with ATAIMH(48.9 years vs.55.6 years,P<0.001).For the total cohort,males were dominant,but the male ratio of patients with ATAAD was significantly higher compared to those with ATAIMH(P=0.01).The time range from the onset of symptom to hospitalization was 2.0 days.More patients of ATAIMH had hypertension than that of ATAAD(82.3%vs.67.6%,P<0.05).Chest and back pain were the most common clinical symptoms.Computerized tomography(CT)was the most common initial diagnostic imaging modality.84.7%received surgical treatment and in-hospital mortality was 5.3%.Patients with ATAAD mainly received surgical treatment(89.6%),while most patients with ATAIMH received medical treatment(39.2%)or endovascular repair(35.4%).Conclusions::Our study suggests that doctors should comprehensively use clinical examination and genetic background screening for patients with ATAAD and ATAIMH and further shorten the time range from symptoms onset to intervention,achieving early diagnosis and treatment,thereby reducing the mortality rate of patients with aortic dissection in China.We should standardize the procedures of aortic dissection treatment and improve people’s understanding.Meanwhile,the curing and transferring efficiency should also be improved.

Esophageal intramural pseudodiverticulosis,a rare cause of food impaction:case report and review of the literature

Esophageal intramural pseudodiverticulosis(EIPD)is a rare,benign condition of uncertain etiology and pathogenesis,which usually presents with either progressive or intermittent dysphagia.Acute presentation with food impaction,requiring emergency esophago-gastroduodenoscopy(EGD),is rare.We report a case of EIPD presenting as food bolus impaction in an elderly black female.The patient had no previous history of dysphagia or odynophagia.Currently accepted risk factors,such as diabetes mellitus,chronic alcoholism,and reflux esophagitis,were not present in our patient.Emergency EGD established the diagnosis and also dislodged the food bolus.Histopathological evaluation of the mucosa diagnosed co-existent acute candidal infection.Medical treatment with proton pump inhibitor and azole antifungal led to resolution of her symptoms.Review of the literature revealed that stenosis,strictures,perforation,gastro-intestinal bleed,and fistula formation are potential complications of EIPD.Multiple motility abnormalities have been described but are not consistent.Treatment of the underlying inflammatory and or infectious condition is the mainstay of management of this unusual condition.

Intramural Hematoma versus Thrombus： Radiation-induced Heart Disease Results in Mass Formation after Radiofrequency Ablation

Radiofrequency catheter ablation （RFCA）,albeit an effective therapy for drug-refractory atrial fibrillation （AF）,can be associated with complications in 3.9-22.0% of cases, of which cerebrovascular embolization,cardiac tamponade,and pulmonary vein stenosis are more common,and atrial hematoma is more rare.Here,we presented a case describing an elderly woman diagnosed with an intramural left atrial hematoma after AF ablation.

A rare case of circumferential intramural dissection of thoracic esophagus with contained esophageal perforation

In this report, a full account of an extremely rare case on esophageal intramural dissection （EID） is presented. A 56-year-old female patient, misdiagnosed as esophageal mediastinal fistula under endoscopic view, was diagnosed correctly as EID with contained esophageal perforation in the operation and cured by thoracic esophagectomy.

The lymphatic drainage systems in the brain:a novel target for ischemic stroke?

Recent studies have proposed three lymphatic drainage systems in the brain,that is,the glymphatic system,the intramural periarterial drainage pathway,and meningeal lymphatic vessels,whose roles in various neurological diseases have been widely explored.The glymphatic system is a fluid drainage and waste clearance pathway that utilizes perivascular space and aquaporin-4 protein located in the astrocyte endfeet to provide a space for exchange of cerebrospinal fluid and interstitial fluid.The intramural periarterial drainage pathway drives the flow of interstitial fluid through the capillary basement membrane and the arterial tunica media.Meningeal lymphatic vessels within the dura mater are involved in the removal of cerebral macromolecules and immune responses.After ischemic stroke,impairment of these systems could lead to cerebral edema,accumulation of toxic factors,and activation of neuroinflammation,while restoration of their normal functions can improve neurological outcomes.In this review,we summarize the basic concepts of these drainage systems,including drainage routes,physiological functions,regulatory mechanisms,and detection technologies.We also focus on the roles of lymphatic drainage systems in brain injury after ischemic stroke,as well as recent advances in therapeutic strategies targeting these drainage systems.These findings provide information for potential novel strategies for treatment of stroke.