1811 Acute Esophageal Necrosis (Black Esophagus): A Rare Cause of Gastrointestinal Bleeding in Patients With Sepsis

Abstract

INTRODUCTION: Acute esophageal necrosis (AEN) is extremely rare with less than one hundred cases reported in the literature. AEN is due to an ischemic insult causing decreased esophageal perfusion. We present two cases of AEN associated with sepsis. CASE DESCRIPTION/METHODS: Case 1: A 78-year-old male with coronary artery and cerebrovascular disease as well as atrial fibrillation on apixaban, was admitted for sepsis from cholangitis. Endoscopic retrograde cholangiography (ERCP) with common bile duct (CBD) stent placement was performed on day 4 which revealed a normal esophagus. He developed hematemesis on day 7; EGD discovered circumferential proximal to distal black esophagus and hematin in the stomach. Treatment included intravenous proton pump inhibitors, antibiotics, and fluid resuscitation. Apixaban was held. The patient did well post EGD and the remainder of his hospitalization was unremarkable. Case 2: A 47-year-old male with fistulizing Crohn’s disease, resulting in subtotal colectomy and diverting colostomy, as well as deep vein thrombosis post IVC filter was admitted for septic shock from gram negative bacteremia. He had hematemesis on day 8; EGD showed black mucosa throughout the entire esophagus and a large duodenal ulcer with visible vessel requiring embolization. Unfortunately, the patient expired from disseminated intravascular coagulation. DISCUSSION: AEN, also termed black esophagus, is rare and lethal, especially among patients with hemodynamic compromise. The distal esophagus is often involved due to blood supply and gastric acid exposure. The etiology is likely multifactorial resulting from entities causing tissue hypoperfusion along with mucosal barrier impairment/injury. Sepsis was present in both cases, with predisposing factors of atherosclerosis and thrombosis. AEN often presents as hematemesis or melena, with diagnosis made endoscopically. Treatment includes hemodynamic support, gastric acid suppression, bowel rest, and management of underlying causes including intravenous antibiotics for septic patients. Complications include esophageal stricture and perforation. Although rare, it is important to have a high index of suspicion for AEN as an etiology for upper gastrointestinal bleeding especially in septic patients given its high morbidity and mortality.