1824 Acute Esophageal Necrosis Secondary to Intrathoracic Gastric Volvulus Without Deadly Outcome

Abstract

INTRODUCTION: Esophageal necrosis is one of the rarely seen conditions of the esophagus. It usually happens in elderly patients and occurs secondary to impaired blood flow in combination with gastric outlet obstruction or gastroesophageal reflux disease. Gastric volvulus is also a rare condition for adults after the age of 50 and is a surgical emergency. Esophageal necrosis and gastric volvulus carry a very high mortality and morbidity if not treated quickly. CASE DESCRIPTION/METHODS: This is an 85-year-old female with past medical history of hypertension and hyperlipidemia. She presented to the hospital with dysphagia to solid food for one week. She complained of abdominal pain, nausea, vomiting, and chest discomfort. Physical examination revealed abdominal distention, mild epigastric tenderness and normal bowel sounds. CT scan of the abdomen and pelvis showed a very large hiatal hernia with the entire stomach herniated into the chest. There was a high clinical suspicion for esophageal necrosis and gastric volvulus given her continued symptoms and thus the decision was made to do an emergent upper GI endoscopy. The upper GI endoscopy showed necrosis of the mid and distal esophagus with a sharp demarcation at the mid esophagus. There was blackish discoloration with severe ulcerative esophagitis in the lower third of the esophagus. There was also a large 7 to 8 cm hiatal hernia with a large para-esophageal component. There was evidence of gastric volvulus. A nasogastric tube was placed endoscopically past the volvulus to decompress the stomach.The patient was taken for emergent laparoscopic surgery. Surgery revealed a large hiatal hernia with intrathoracic stomach, and lower esophageal necrotic ulcerations with perforation. This was evidenced by a 7 mm sized opening at the left lateral distal esophagus with leakage of saliva and gastric contents. The perforation and hiatal hernia were repaired and a G tube was placed. Patient did very well and was discharged home two weeks after surgery. DISCUSSION: Diagnosis of acute esophageal necrosis is often incidental during upper GI endoscopy for evaluation of upper GI bleeding. There are no laboratory or imaging findings specific for acute esophageal necrosis. A high clinical suspicion and urgent upper GI endoscopy are needed to make the diagnosis. This case demonstrates that emergent upper GI endoscopy followed by surgical repair can lead to a favorable outcome.