A Black Esophagus

Abstract

A 54-year-old woman with type II diabetes mellitus presented with a 3-day history of vomiting and mild abdominal pain. She was afebrile, tachycardic and severely hypertensive. Her abdomen was non-tender and without guarding. Laboratory evaluation revealed hyperglycemia, acidosis, acute kidney injury and elevated troponin. She was admitted with a diagnosis of diabetic ketoacidosis and hypertensive emergency. Overnight, she developed melena. Upper endoscopy revealed an esophagus with black necrotic tissue from 23cm to 32cm from the incisors, ending abruptly at the gastroesophageal junction. The patient was kept nothing per mouth and started on intravenous pantoprazole. Repeat endoscopy 6 days later showed healing of the esophageal necrosis and ulceration. Her diet was advanced, and she was switched to oral pantoprazole. Two weeks later, repeat endoscopy revealed LA class D esophagitis, which appeared substantially improved. Acute esophageal necrosis (AEN) is a rare condition with prevalence between 0.001 to 0.2%. It is characterized by circumferential black mucosa in the esophagus. It most commonly manifests as upper gastrointestinal bleeding, but it can also cause dysphagia, chest pain, or epigastric pain. Risk factors include male sex, age, cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol ingestion, malnutrition, diabetes, renal insufficiency, hypoxemia, and hypercoagulable state. Diagnosis is based on the findings of upper endoscopy with the appearance of black necrotic tissue, mostly in the distal esophagus, and terminates at the gastroesophageal junction. Histology is not required for diagnosis, but it can be helpful to rule out other causes. Etiology is multifactorial, including tissue hypoperfusion due to an ischemic insult, impaired local barrier defenses, and acid reflux. Management is conservative with bowel rest, acid suppression, and hydration with restoring hemodynamic stability. Treating the coexisting medical condition is crucial, as AEN has been associated with different medical conditions, including diabetic ketoacidosis. Complications include esophageal stricture, mediastinitis, infection or abscess, and esophageal perforation. Death has been reported, with a mortality rate of 6% due to AEN, and as high as 32% due to the underlying medical condition. Therefore, high clinical suspicion and appropriate diagnosis and management are important to save the patient's life.FigureFigureFigure