Idiopathic esophageal intramural hematoma associated with hemothorax leading to esophageal perforation

Idiopathic intramural hematoma of the esophagus is a rare condition associated with Mallory–Weiss syndrome or spontaneous esophageal rupture. It is usually manageable with conservative treatment but, in rare cases, may be complicated by hemothorax or progress to esophageal perforation. We report the case of a 56-year-old man with right-sided paralysis following a stroke who was taking aspirin. He presented with chest pain, a suspected mediastinal tumor, and right pleural effusion on CT. At our hospital, contrast-enhanced CT suggested a mediastinal hematoma with contrast leakage. He had no hematemesis or vomiting, and his vital signs were stable. On the fourth hospital day, he developed tachycardia and inflammatory changes. CT revealed pneumothorax, and oral contrast confirmed leakage from the esophagus into the right thoracic cavity. Emergency surgery revealed a large bloody pleural effusion, hematoma, and a 4-cm longitudinal tear of the esophageal muscular layer. Esophagectomy with cervical esophageal fistula and gastrostomy was performed. Pathological examination demonstrated a hematoma extending from the adventitia to the muscularis propria, with an acute, well-defined tear and no neoplastic lesion, consistent with idiopathic intramural hematoma. We report a rare case of idiopathic esophageal intramural hematoma with hemothorax leading to esophageal perforation, successfully treated by surgical intervention.