title: Intramural oesophageal dissection as an unusual presentation of chest pain: A case report.
abstract: BACKGROUND
  Intramural oesophageal dissection (IOD) is a rare clinical condition and there is a paucity of information regarding the appropriate diagnosis and management. It is described as bleeding in the submucosal plane of the oesophagus, and has various documented causes.
  
  
  METHODS
  We report a case of a 73 year old female who developed IOD. She presented with severe chest pain. Subsequent imaging revealed IOD and haematoma formation. This was confirmed on oesophagogastroduodenoscopy (OGD). She was on a bisphosphonate for her osteoporosis, as well as having age-related dysmotility of her oesophagus on manometric studies. She was also taking fish oil. Treatment was conservative and the patient was discharged with proton pump inhibitors and follow up.
  
  
  CONCLUSIONS
  Spontaneous haematoma formation and IOD resulted likely from a combination of the anticoagulant effect of fish oil and oesophageal dysmotility. Bisphosphonates also have some well documented gastrointestinal side effects involving mucosal damage. The possibility that the concurrent use of bisphosphonate led to a pre-existing ulcer which could have contributed to the development of IOD in this patient should be considered.
  
  
  CONCLUSIONS
  spontaneous IOD can occur in elderly patients who are anticoagulated. Fish oil has not been previously reported as having an association with IOD. This is the first known reported case of spontaneous IOD occurring in association with concurrent use of a bisphosphonate and fish oil. IOD is a rare disorder, and any anticoagulated patients presenting with severe chest pain may need careful investigation prior to definitive management.
authors.affiliation: Department of Surgery, Hervey Bay Hospital, Urraween Road & Nissen Street, Pialba QLD 4655, Australia.
authors.forename: Ryo
authors.initials: R
authors.lastname: Mizumoto
authors.affiliation: Department of Surgery, Hervey Bay Hospital, Urraween Road & Nissen Street, Pialba QLD 4655, Australia.
authors.forename: Henk
authors.initials: H
authors.lastname: Van Rooyen
keywords: Bisphosphonate fosamax; Fish oil anticoagulation; Intramural oesophageal dissection; Oesophageal haematoma