Probable intramural esophageal hematoma mimicking esophageal abscess

Intramural esophageal hematoma is an uncommon condition that may mimic esophageal abscess on initial imaging. We report a 43-year-old man who presented with three days of odynophagia and dysphagia, aggravated by swallowing hard food, followed by abrupt severe epigastric pain. Initial CT showed a long upper esophageal intramural fluid-density lesion with wall thickening, raising concern for esophageal abscess. He had leukocytosis, and fever with elevated C-reactive protein developed during hospitalization; antibiotics were therefore administered because abscess or secondary infection could not initially be excluded. Repeat CT approximately 14 hours later showed interval intraluminal decompression without rim enhancement, intralesional gas, mediastinal fat stranding, extraluminal air, or contrast leakage. Upper endoscopy showed a dark-red submucosal bulge with mucosal rupture. The patient improved with fasting, parenteral nutritional support, acid suppression, antibiotics, and observation, without endoscopic drainage or surgery. Follow-up endoscopy at six weeks showed healing, and no recurrence occurred during six months of follow-up.