A Rare Case of Acute Esophageal Necrosis in a Patient with Alcoholic Cirrhosis

Abstract

A 55-year-old man with alcoholic cirrhosis presents after being found unresponsive at home. On route to the hospital, he had multiple episodes of coffee ground emesis. On admission, he was hemodynamically unstable and remained unresponsive. He was intubated, given packed red blood cells, started on nexium, octreotide and norepinephrine drips, and admitted to the MICU. An upper endoscopy revealed diffuse necrotic appearing esophagus, with confluent dark black areas and intermittent pale mucosal patches throughout the entire esophagus, but sparing the gastroesophageal (GE) junction. Hematin with diffuse moderate inflammation was seen in the gastric fundus and duodenum. Esophageal biopsies showed extensive necrotic debris with inflammation and black pigment deposition along the surface, consistent with acute esophageal necrosis (AEN). CT abdomen/pelvis showed a new pancreatic body mass with diffuse lymphadenopathy and nodules in lung, liver and adrenals. Superclavicular lymph node biopsy was consistent with pancreatic adenocarcinoma. Following biopsy, he remained encephalopathic and in persistent hemorrhagic and cardiogenic shock. He was transitioned to comfort care and expired from multi-system organ failure. Acute esophageal necrosis, or “black esophagus,” is a rare disorder, with a prevalence of approximately 0.2 percent.1 The condition is described as diffuse, circumferential black mucosal discoloration predominantly affecting the distal third of the esophagus and sparing the GE junction. The etiology is multifactorial and includes ischemic injury, corrosive injury from gastric contents in the setting of impaired motility, and impaired mucosal barrier systems.2 The most common risk factors include underlying malignancy and alcoholic cirrhosis. 70% of cases present with hematemesis and melena. Esophageal biopsies, however, are necessary to differentiate AEN from other etiologies.2 Management is largely supportive, aimed at correcting coexisting clinical conditions, as well as bowel rest and intravenous acid suppression with proton pump inhibitors. Complications include strictures, superinfections and perforation. While AEN does have a high mortality rate of 32%, it is largely due to the underlying clinical disease.2 Overall, acute esophageal necrosis is a rare condition, which should be viewed as a poor prognostic factor.Figure 1