Acute Esophageal Necrosis

Abstract

Purpose: Acute Esophageal Necrosis, also called “black esophagus”, is a rare endoscopic finding that can be fatal. The most common appearance is diffuse circumferential black discoloration at the distal esophagus with extension ending abruptly at the gastro esophageal junction. The most common settings in which acute esophageal necrosis occur are hypoperfusion, vasculopathy, sepsis, traumatic transection of the thoracic aorta, and gastric outlet obstruction. Most patients present with upper GI bleeding and a variety of symptoms including epigastric pain, vomiting, or dysphagia. HPI: A 72-yearold male was evaluated in the emergency room for a six hour history of a throbbing headache and epigastric abdominal pain. On day two of the hospital admission, the patient began to complain of black tarry stools, and his hemoglobin dropped from 13.1 g/dl at admission to 9.4 g/dl. A nasogastric tube was placed which showed coffee ground aspirate. An EGD was performed on hospital day two showing acute esophageal necrosis. Discussion: Acute esophageal necrosis is most commonly seen in elderly males, and based off a literary review, the pathophysiology is multi-factorial. The most common identifiable cause is a poor perfusion state to the distal third of the esophagus. Further research also suggests that exposure of the distal third of the esophagus to increased amounts of hydrogen ions, bile salts, and pepsin from reflux fluid leads to a further decline in local esophageal blood flow. In most documented cases, the treatment for acute esophageal necrosis is supportive care. Medical management includes intravenous proton pump inhibitors until an improvement in overall clinical status. Oral therapy is recommended for three months after the resolution of symptoms to aid in the prevention of future complications such as stricture formation. The most common complications of acute esophageal necrosis are full thickness necrosis and esophageal perforation, which occur in 7% of patients. In addition, the most common long-term complication is the development of esophageal strictures occurring 10% of the time.Figure: Acute esophageal necrosis.