Acute Esophageal Necrosis: The Black Hole of Endoscopy

Abstract

Acute esophageal necrosis (AEN) is a rare condition that appears as circumferential necrotic mucosa of the distal esophagus. With a prevalence of 0.2% in autopsy series and 0.001-0.2% in endoscopy series, little is known about the etiology of AEN. What we do know is that AEN has a 4:1 predilection to males and the mean age of diagnosis is 68 years. Many of the patients previously described had multiple comorbid conditions that include but were not limited to ischemia, malnutrition, vascular diseases, diabetes mellitus, and septic shock. With a mortality rate of 13-35%, further knowledge of AEN and recommended management is essential. We present a case of a 94 year old male with a past medical history of hypertension, hyperlipidemia, acute on chronic renal disease, COPD, anemia, and previous CABG s/p stenting and heart valve repair that was admitted to the hospital for urosepsis, failure to thrive, and hyperkalemia. Hemoglobin upon admission was 11.8 and WBC was elevated at 13.3. Lactic acid remained within normal limits. On day 3, the gastroenterology service was consulted for dysphagia and failed MBS to evaluate for PEG placement, which was denied by the patient's proxy. On day 4, the patient's condition significantly deteriorated and he aspirated. Nasogastric tube was subsequently placed and 200 cc of bloody gastric contents were suctioned. The patient's hemoglobin dropped from 12.0 to 10.4 overnight. A KUB was performed and showed no acute findings. The patient was started on PPI and Octreotide drips. Urgent endoscopy revealed grossly black appearing mucosa in the upper, mid, and lower esophagus consistent with necrosis. Stomach and duodenum revealed antral gastritis and multiple large, clean-based ulcers in the duodenal bulb with no active bleeding respectively. The patient was continued on protonix and octreotide drips and kept NPO. The patient passed away the following day. This patient presented with many of the risk factors described in AEN. Unfortunately, with his rapid decline, management in this case was highly limited. In general, AEN management focuses on intravenous fluid resuscitation, PPI therapy, and treatment of the patient's comorbid conditions. Early endoscopic detection is essential in order to begin prompt treatment of the patient's comorbidities that could potentiate a case of AEN.1744_A Figure 1. Diffuse and circumferential necrosis of the esophagus1744_B Figure 2. Diffuse and circumferential necrosis of the esophagus1744_C Figure 3. Diffuse and circumferential necrosis of the esophagus