Acute Esophageal Necrosis Masquerading Colon Cancer

Abstract

The Case: A 43 yo AAM with a past medical history of HTN, DM, ESRD on dialysis presented to the ER with intractable hiccups for 2 days along with N/V, retrosternal non cardiac chest pain and mild epigastric pain. Review of systems was notable for constipation and occasional wipe type rectal bleeding. Physical examination was unremarkable except for RUE dialysis access. His vital signs were stable. Acute coronary syndrome was ruled out. Notable labs included- WBC 20,300/μL, Hgb 14.7 g/dL, Na+ 128 mmol/L, anion gap 25.0 and pH of 7.1. A CT scan of chest/abdomen/pelvis with IV contrast revealed a dilated fluid filled esophagus with distal esophageal wall thickening and a rectosigmoid intussusception. EGD revealed a black distal esophagus extending 15 cm superiorly to the middle esophagus but sparing the GE junction, and colonoscopy identified a 5 cm nearly obstructing rectosigmoid mass. Histopathology reported esophageal biopsies as fragments of ulcerated mucosa with acute inflammation and fibrinoid necrosis consistent with acute esophageal necrosis (AEN). The colon mass was found to be a tubulovillous adenoma with high grade dysplasia, however biopsies could have been superficial. He was initially treated with NPO and thorazine that resolved his hiccups. Sucralfate and high dose PPI were added after EGD. Slowly diet was advanced and he tolerated well. A follow up EGD in 4 weeks was scheduled. He was also referred to surgical oncology for the management of colon mass. Discussion: Acute esophageal necrosis is rare (prevalence ˜ 0.2%). AEN mainly affects men with an average age at onset of 67 years. DM, CKD, cardiovascular diseases pose greater risk for AEN. Typically AEN presents with upper GI bleeding with associated nausea, dysphagia and abdominal pain. Endoscopically there is circumferential blackening of the distal esophagus that spares the GE junction. Treatment consists of NPO and aggressive acid suppression. The true etiology of AEN is unclear. Although case studies have postulated an association with an underlying malignancy, no specific cancers have been discussed. Here we report a case of colon cancer associated with AEN. Additionally, intractable hiccups as a presentation has not yet been reported. Compared to prior studies, the diagnosis of AEN in this young patient is atypical and unique.Figure 1