oesophageal perforations are associated with high morbidity and mortality , predominantly as a result of a mediastinal leakage frequently leading to septic shock .
we report a patient on warfarin therapy presenting an intramural , intrathoracic eosophageal haematoma prior to oesophagus perforation ; a condition that to our knowledge is not previously reported . in our patient ,
an initial conservative approach was used in managing the haematoma and once perforated prompt surgical intervention was initated .
a 84-year - old women presented to the emergency room after she slipped and fell causing blunt traumas to the chest and face .
she was conscious , hemodynamically stable and had normal blood counts besides a low albumin of 34  g / l ( 3445 
the patient was on warfarin treatment due to atrial fibrillation and a history of pulmonary embolisms , and suffered furthermore from recurrent urinary tract infections and pulmonary fibrosis .
initial computed tomography ( ct ) revealed a 4  cm    6  cm    15  cm paraoesophageal haematoma located in the superior and posterior mediastinum ( fig .
initially the haematoma was treated conservatively but during the course of hospitalization the patient developed increasing difficulty swallowing and on the 18th day , the patient 's condition rapidly deteriorated with fever , tachycardia , acidosis and leukocytosis .
an immediate ct scan showed mediastinal leakage corresponding the known location of the haematoma ( fig .
2 ) . due to mediastinal leakage and unknown consequences of stent - treating a haematoma of this size
this revealed no intra- or extramural necrosis but an extremely tense haematoma and further confirmed a 3  cm longitudinal oesophageal perforation .
the perforation was directly sutured ; no reinforcements were applied . until recognition of the perforation the patient was on proton pump inhibitors and soft diet , and during the post - op stay antibiotics and parenteral nutrition .
the patient began full diet 10 days prior to discharge . due to a complicated post - op stay with fungal and bacterial infection
we report an intramural , intrathoracic esophageal haematoma with late rupture as a result of blunt trauma to the chest .
earlier cases describe intramural small bowel haematomas in patients using warfarin but our case is extremely rare .
our patient 's single complaint was chest pain and although anticoagulant therapy was discontinued , late complications to haematomas are possible .
likely , the perforation might be due to ischemia from the pressure built up between the haematoma , vena azygos and the distal trachea ; or the oesophageal rupture was immediate present after the trauma and the haematoma walled it off until the patient became symptomatic .
early diagnosis and management of oesophageal perforation is difficult but imperial in reducing morbidity and mortality . whether surgical or conservative treatment is indicated depends mainly on the general health of the patient , time elapsed and the size of the perforation .
thoracic esophageal perforations are usually differentiated in those contained within the mediastinum and those noncontained that drain into the pleural space as with our patient .
primary stent treatment for spontaneus esophageal perforations especially in iatrogenic perforations has proven effective but outcomes for stent treating haematomas are unknown and require close radiographic and endoscopic follow - up . as to our knowledge ,
no guidelines on traumatic blunt perforations with haematomas are available , and we believe as indicated by others , that stent treatment should be reserved for patients not fit to undergo major surgery like thoracotomy , or as 2nd line management in persistent leak or sepsis once a perforation is verified management should always include antibiotics , proton pump inhibitors and parenteral nutrition as vital therapeutic measures .
if choosing to treate an oesophageal hematoma conservatively we advise to stop anticoagulants or lead strict control of international normalised ratio ( inr ) when prescribing vitamin - k - antagonists . to prevent esophageal lesions , it is advisable to refrain from gastric tubes and instead consider parenteral nutrition . as with our patient ,
chest pain is the most frequent symptom but other symptoms such as fever , dyspnoea and dysphagia might dominate .
late , spontaneous , intrathoracic esophageal perforations due to blunt trauma is to our knowledge not described previously .
such haematomas can be treated conservatively but if the esophageal wall ruptures prompt surgically management must be taken , especially if uncontained .
 introductiontraumatic oesophageal perforation is a rare , life - threatening emergency that requires early recognition and prompt surgical management.presentation of casewe present an unusual case of a patient on warfarin treatment developed an intramural oesophageal haematoma following blunt thoracic trauma leading to perforation on the 18th day.discussionin treatment of oesophageal haematoma in patients on vitamin - k antagonists , strict control of the international normalized ratio ( inr ) is essential along with total parenteral nutrition therapy and refrainment through nasogastric tubes . 
 three explanations postulated to be the cause for late perforation which might be due to esophageal wall ischemia from pressure built up between the hematoma , azygos vein and the lower part of thoracic trachea ; or could be an immediate rupture walled - off until the patient became symptomatic ; or the intramural hematoma gradually lysed and causing late perforation.conclusionalthough extremely rare , an oesophageal haematoma and late complications must be considered in patients on anti - coagulant therapy following blunt thoracic trauma and complaining only of chest pain . 
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