1701 An Aggressive Case of Recurrent Esophageal Stricture in a Patient With Acute Esophageal Necrosis

Abstract

INTRODUCTION: Esophageal strictures are a known complication of acute esophageal necrosis (AEN). Our patient presented with dysphagia and after EGD was found to have AEN complicated by an esophageal stricture requiring recurrent dilation. CASE DESCRIPTION/METHODS: 82 y/o male with PMH of HTN and prostate cancer was status post right sided orchiectomy for recurrent orchitis. After surgery, patient disclosed a 2-month history of dysphagia to solids. He reported food “getting stuck” and a 20 lb weight loss in 2 months. EGD showed white exudate in the proximal and mid esophagus that easily sloughed off. The mucosa was ulcerated with underlying granulation tissue (Figure 1). Brushings were negative for candida. Biopsy results from both proximal and distal esophagus showed marked necroinflammatory debris. Patient denied caustic ingestion. Serologic testing was normal. Patient was discharged on a liquid diet, pantoprazole 40 mg PO BID, sucralfate with EGD in 2 months. He returned 1 month later for worsening dysphagia. EGD revealed esophagitis in the mid and distal esophagus and a stricture at 36 cm (Figure 2). The white exudate had improved, but the mucosa was fibrosed. Using a Savary dilator, the stricture was dilated to 7 mm. Over the next 2 weeks, 3 EGD’s with dilation were required for recurrent stricture. On the 4th visit he reported retching and coffee ground emesis for 3 days. EGD revealed an esophageal tear at the stricture site (Figure 3). At the 5th visit, patient was asymptomatic and tolerating a clear liquid diet. EGD showed scarring and fibrosis of the esophageal mucosa and a stricture that was dilated to 12 mm. He will be followed closely due to concern for reformation of the stricture. DISCUSSION: AEN has been associated with infections, antibiotics, malignancy, prolonged vomiting etc. It is proposed that a low flow vascular state leaves the esophagus vulnerable to topical injury from acid reflux and pepsin. On EGD, a circumferential black discoloration with underlying friable hemorrhagic tissue is seen with a sharp transition point to normal appearing mucosa at the GE junction. The esophagus may have thick, white exudates that can be dislodged easily to reveal pink granulation tissue. Histology reveals necrosis of the esophageal mucosa and submucosa. Supportive care leads to endoscopic resolution in most patients. Esophageal stricture occurs in 25-40% of patients and requires dilation. Our patient required repetitive dilation as his stricture redeveloped rapidly. He may need PEG for nutritional support.