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Haematemesis and chest pain in a middle-aged women.

A 57-year-old woman presented with acute-onset sharp retrosternal chest pain which occurred whilst walking. The pain radiated to her back and was associated with coffee-ground vomiting. She had eaten a meal two hours before with no discomfort. There was no previous history of ischaemic heart disease, hypertension, peptic ulcer disease or gastro-oesophageal reflux disease and she was not taking aspirin or any other nonsteroidal anti-inflammatory drug. On examination she was well and had no surgical emphysema. The pulse was 90 beats/min and the blood pressure 150/85 mmHg being equal in both arms. The respiratory and abdominal system were unremarkable. Routine biochemical and haematological parameters were normal apart from a haemoglobin of 11.8 g/dl and a mean corpuscular volume of 88 fl. Her C-reactive protein (CRP) was 28 mg/l. The chest X-ray and electrocardiogram were normal. She was then kept nil by mouth and intravenous fluids were started. She then had an urgent oesophagogastroduodenoscopy which showed a submucosal haematoma extending from 18-40 cm (figure 1). On retroversion of the endoscope there was an ulcerative area at the cardia, histology of which showed fibrinous debris but no evidence of malignancy. Computed tomography (CT) scan of the thorax showed a dilated proximal oesophagus with oesophageal wall thickening which narrowed to the level of the left pulmonary artery but no evidence of pathological lymph nodes or masses.