A 45-year-old man was in the middle of a meal when sudden pain struck behind his breastbone, and he began vomiting blood. He had heart disease and took daily aspirin, so his doctors' first concerns were a heart attack or a torn aorta.
It was neither. Imaging and an endoscopy showed that blood had collected inside the wall of his esophagus, forming a long mass that stretched from his mid-chest to the top of his stomach.
The case, published in April 2026 in Clinical Case Reports by Ian Seng Lam, Hoi Ip Leong and Tam Fei Chang of the emergency department at Centro Hospitalar Conde de São Januário in Macau, China, describes a condition called intramural hematoma of the esophagus. It is rare, easy to mistake for something deadlier and, as this case shows, often heals without surgery.
A Meal That Turned into a Chest Pain Emergency
The man had high blood pressure and coronary artery disease. He was taking aspirin, the blood pressure drug amlodipine, and the cholesterol drug atorvastatin. According to the report, he arrived with "sudden-onset retrosternal pain and hematemesis that occurred while he was eating," meaning pain behind the breastbone and vomiting of blood.
Unlike many people with esophageal injuries, he had not been retching or vomiting beforehand, and he had not recently had an endoscopy, a feeding tube, or any other procedure involving his esophagus.
His blood pressure was high at 168/95 mmHg, but his other vital signs were normal. So were his blood counts and clotting tests. His hemoglobin was 15.8 g/dL, suggesting he had not yet lost a large amount of blood.
Ruling Out the Heart and the Aorta First
In a patient with heart disease and sudden chest pain, the first job is to rule out conditions that can kill quickly. An electrocardiogram showed a sinus rhythm "without ST-T changes," the pattern doctors look for in a heart attack.
The team also had to exclude an aortic dissection. The National Heart, Lung, and Blood Institute describes it as "a partial tear of the innermost lining of the aorta" and notes that chest pain is its most common symptom, sometimes described as sudden and crushing or as ripping and tearing.
A contrast-enhanced CT scan of the chest showed no dissection and no rupture of the esophagus. Instead, it revealed a "non-enhancing soft tissue mass in the posterior mediastinal space," running along the esophagus from the upper chest to the stomach.
An endoscopy confirmed what it was: a "longitudinal submucosal hematoma extending from 25 cm distal to the incisors to the lesser curvature side of the gastric cardia." In plain terms, a long pocket of blood sat beneath the esophagus lining and reached into the top of the stomach. Doctors also saw blood clots in his stomach.
Aspirin, Blood Thinners and a Bleed That Healed Itself
The authors reviewed earlier research. A review of 174 reported cases found that patients were typically middle-aged, with an average age of 58.8, and that cases peaked around ages 45 and 70. The condition was slightly more common in women.
In a separate review of 91 cases, only 35% of patients had the classic trio of chest pain, painful or difficult swallowing, and vomiting blood. That helps explain why the condition can be confused with other emergencies, including heart attacks, bleeding ulcers and esophageal tears.
The authors note that "antiplatelet therapy is also considered a risk factor" for cases that arise without an obvious trigger. A federal medical reference on esophageal hematoma likewise links anticoagulants, antiplatelet drugs and clotting disorders to the condition. The man's daily aspirin fits that picture, though a single case cannot show that aspirin caused his bleed, and his clotting tests were normal.
Treatment was deliberately conservative. He was admitted to intensive care, where doctors stopped his aspirin and gave intravenous acid-suppressing medication and pain relief. Because he kept vomiting blood, he was intubated and placed on a ventilator to protect his airway. No surgery or endoscopic procedure was needed.
He recovered quickly. A repeat CT on day 3 showed "complete resolution" of the mass, and he came off the ventilator that day. He went home on day 6 and had no recurrence over six months of follow-up. According to the authors, most patients recover with similar supportive care, and symptoms typically resolve within two weeks.
A Rare Mimic That Still Calls for a 911 Response
The case is not a reason to shrug off chest pain. The authors stress that "prompt CT imaging is crucial for accurate diagnosis and exclusion of vascular emergencies," and that conservative care leads to excellent outcomes once the diagnosis is clear.
For the public, the message matches what heart experts say. The American Heart Association advises, "Call 911 if you have any symptoms of heart attack." Vomiting blood also calls for immediate care; the National Library of Medicine says it can indicate a serious medical problem.
For clinicians, the report is a reminder that a patient on aspirin who develops chest pain and vomits blood during a meal may have a problem in the esophagus rather than the heart. Recognizing it can spare patients unnecessary procedures.
People who take aspirin for heart disease should not stop it on their own because of this case. Anyone with questions about bleeding risk should talk with the clinician who prescribed it.
Key Questions Answered
What is an intramural esophageal hematoma?
It is a collection of blood inside the wall of the esophagus, beneath its lining. It can form a long mass that narrows the swallowing tube.
What happened to this patient?
A 45-year-old man with heart disease who took aspirin developed sudden chest pain and vomited blood while eating. An endoscopy found a hematoma running from his mid-esophagus into the top of his stomach.
Why did doctors first check his heart and aorta?
Sudden chest pain in someone with coronary artery disease can signal a heart attack or aortic dissection, both of which can be fatal. An ECG and a CT scan ruled those out.
Does aspirin cause this condition?
Antiplatelet drugs like aspirin are considered a risk factor, but this single case does not prove aspirin caused his bleed. His clotting tests were normal.
How was it treated?
Doctors paused his aspirin and gave IV acid-suppressing medication, and he was briefly placed on a ventilator to protect his airway. The hematoma was gone on a CT scan by day 3, and he went home on day 6.
What should someone do if they have chest pain and vomit blood?
Call 911 or seek emergency care right away. Only a medical evaluation can tell a heart or aortic emergency apart from an esophageal problem.
Published by Medicaldaily.com
