1813 A Killer in the Dark: The Black Esophagus

Abstract

INTRODUCTION: Acute esophageal necrosis, also known as “black esophagus” is a rare condition of unclear etiology. Only 88 patients were diagnosed over a period of 40 years. It is diagnosed by endoscopy showing darkly pigmented necrotic esophageal mucosa. Prognosis is poor, with a mortality rate of 31.8-50%. We report a case of this condition in an elderly woman who presented with hematemesis and sepsis. CASE DESCRIPTION/METHODS: A woman aged 72 presented after a fall with head strike without loss of consciousness. CT head was unremarkable. That evening, she had an episode of coffee-ground emesis associated with hypotension, tachycardia, and worsening mental status. Hemoglobin was 6.1, raising suspicion of GI bleed. However, she developed leukocytosis without abdominal pain or melena, suggesting septic shock. She received fluids and antibiotics with no improvement. CTPA showed bilateral pulmonary embolism. Anticoagulation was held given concern for GI bleed. Later a massive transfusion protocol was activated when hemoglobin dropped to 4.8; 400 cc of blood was aspirated from the stomach. She received 3U pRBCs, 1U FFP, 1U platelets, 500 cc albumin and vasopressors with improvement of hemoglobin to 11. She then became increasingly acidotic and hypothermic for which a bair hugger was placed. An EGD revealed a severely inflamed esophagus with black material extending from the mid esophagus to the gastroesophageal junction, consistent with esophageal necrosis, the likely source of her GI bleed. The patient stopped following commands, moving extremities or responding to pain. Despite maximal measures, the patient’s hemodynamic instability worsened and she died. DISCUSSION: Acute necrotizing esophagitis is a fatal condition that commonly presents with hematemesis or melena. It is associated with multiple factors including diabetes, hemodynamic instability, trauma, hypercoagulable state, gastric volvulus, and some infections. While the pathophysiology is not well known, it is hypothesized that the condition results from an ischemic insult. Esophageal perforation, stricture, infection and death are the main complications. As with our patient, the most likely cause of death are underlying comorbidities such as infections, sepsis, hypovolemic shock or pulmonary embolism, while underlying esophageal disease as the cause of death have been reported in only less than 10% of patients. Elderly patients with comorbidities like diabetes and vascular disease, presenting with upper GI bleed must always get an upper GI endoscopy.