Acute Cholecystitis Induced Esophageal Necrosis

Abstract

Purpose: Acute esophageal necrosis (AEN), colloquially referred to as “black esophagus,” is extremely rare. Retrospective case series over 45 years document only 95 patients with AEN. The hallmark presentation on EGD is diffuse circumferential black mucosa found in the distal third of the esophagus. Here we describe the first case of AEN caused by cholecystitis. A 65 y/o male with hepatitis C decompensated cirrhosis presents with coffee-ground emesis and severe abdominal pain. He recently had an uncomplicated sphincterotomy and stent placement for choledocholithiasis. Labs show WBC 36.9 K/μL, Hgb 9.2 g/dL (baseline 13), platelets 97 K/μL, INR 2.5, Cl 81mmol/L, and lactic acid 18.7 mmol/L. Serum lipase, amylase, CPK, and transaminases were normal. CT reveals an intact biliary stent with pneumobilia, markedly distended gallbladder, abundant ascites, and a thick-walled esophagus. EGD demonstrates circumferential necrotic appearing mucosa from mid to distal esophagus. Ascites grew Citrobacter, Klebsiella; blood grew Klebsiella, Staph. Antibiotics, albumin, TPN were started. Repeat paracentesis reveal WBC 8660, 89% PMNs with growth of Klebsiella, Pseudomonas, and Vancomycin resistant Enterococcus. Patient was intubated for hypoxia. A hydropic gallbladder with thickened edematous wall, pericholecystic fluid, and sludge seen on ultrasound. Peritoneal fluid amylase and bilirubin were normal. During percutaneous choleycstostomy tube placement, cholangiogram confirmed no filling of the cystic duct consistent with cholecystitis; cultures revealed identical organisms as in peritoneal fluid. His overall septic course decompensated and palliative care was pursued. The patient passed. AEN is caused by significant hypoperfusion resulting in profound ischemia. Upper gastrointestinal bleeding is the most common presenting symptom. AEN is diagnosed clinically and treatments are conservative in nature: optimize perfusion, nutrition, and treat infection if present. Our case is unique as AEN was due to bacterial peritonitis from cholecystitis, leading to a massive ischemic event.Figure: No Caption available.