Acute Esophageal Necrosis: A Cause or Effect of Diabetic Ketoacidosis (DKA)?

Abstract

Despite having an incidence of 0.01 - 0.28%, Acute Esophageal Necrosis (AEN) should be considered when a patient with DKA presents with symptoms of an upper GI bleed. Our case report highlights one such presentation. A 30-year-old woman with a history of Type 1 diabetes was brought to the ED by paramedics for altered mental status. On the day of admission, the patient texted her sister to say that she had vomited a dark substance. Her messages became progressively less coherent during the day and as a result, her sister went to check on her, finding her unresponsive on the floor. On admission, the patient was relatively hypotensive (BP 90/50 mmHg), tachycardic (HR 132 bpm), and tachypneic (RR 32/min). Exam was notable for diffuse abdominal pain and Kussmaul respirations. Laboratory results were remarkable for leukocytosis (WBC 45 K/cu mm), hyperglycemia (BG 1294 mg/dL), and high anion gap metabolic acidosis (Bicarbonate 4 mmol/L, Anion Gap 32 mmol/L, Venous Blood pH < 6.8). She was admitted to the intensive care unit for DKA and shortly thereafter was noted to have 2 episodes of coffee ground emesis. Infectious work-up did not reveal a potential cause for her DKA. She denied feeling ill prior to the day of her admission and reported adherence to her insulin regimen. Her white count down-trended without antimicrobials and her blood glucose was controlled on a slight adjustment to her home insulin regimen. The patient underwent an esophagogastroduodenoscopy (EGD) which revealed an area of necrosis with overlying black eschar in the distal esophagus - diagnostic of acute esophageal necrosis. Her diet was advanced as tolerated and she was discharged on a proton pump inhibitor. Plans were made to repeat EGD within eight weeks to check for healing of her esophageal mucosa. This case illustrates the association between DKA and AEN. AEN is a rare syndrome that arises due to a combination of factors including ischemic insult seen with hemodynamic compromise, corrosive injury from gastric outlet obstruction or gastroparesis, and decreased function of mucosal barrier systems in malnourished patients. It tends to occur in the distal third of the esophagus, which is relatively hypo-vascular compared with other esophageal segments. The cause and effect relationship of DKA and AEN has not been cited in the literature. One might think that given the chronology of this case, the trigger for this patient's DKA was AEN; however, the mechanism remains unclear.Figure: EGD demonstrating AEN of distal esophagus.