A Rare Etiology of Upper Gastrointestinal Bleeding

Abstract

Purpose: A 47-year-old male with a history of alcohol abuse, diabetes, and hypertension was admitted with alcohol intoxication and Clostridium difficile infection for which he was treated with flagyl. On day 4 of admission, patient developed hematemesis associated with retrosternal burning. His hemoglobin dropped from 10.1g/dl to 6.4g/dl. Patient was resuscitated with intravenous (IV) fluids and transfused two units of blood. Patient was also started on IV protonix drip and Carafate. Airway was protected by intubation and an emergent esophagogastroduodenoscopy (EDG) was performed which showed circumferential necrotic appearing mucosa which was grayish black in color, involving the distal 30 cm of esophagus. Spontaneous oozing and mucosal sloughing was noted at multiple sites. Patient remained intubated for three days following EGD. No more bleeding episodes were noted. He received peripheral nutritional for one week and was subsequently discharged. Acute esophageal necrosis (AEN) also called black esophagus is a rare disorder characterized by diffuse, circumferential, black appearing distal mucosa on EGD that abruptly stops at gastroesophageal junction (GEJ). Incidence ranges from 0.01 -0.28% and occurs usually in sixth decade of life. Men are affected four times more than women. Etiology is multifactorial and results from a combination of tissue ischemia, impaired local defense barriers, and massive influx of gastric contents that alter the already affected esophageal mucosa. Other risk factors include diabetes, hemodynamic compromise, hypercoagulable state, alcohol intoxication and debilitated/malnourished clinical status. Patients commonly presents with epigastric/abdominal pain, hematemesis, melena, nausea and fever. Diagnosis is usually made on EGD but histologic tissue necrosis is confirmatory. Complication includes perforation, infection of necrotic tissue and strictures. Treatment is supportive with correction of underlying clinical condition, resuscitative measures and intravenous acid suppression with proton pump inhibitors. Mortality tends to be high, mostly due to underlying comorbidities. Surgery is reserved for complications. Our case highlights the fact that early diagnosis on endoscopy and aggressive supportive measures can be life-saving in this rather fatal clinical condition.