An Atypical Presentation and Management of Acute Necrotic Esophagus and Esophageal Perforation

Abstract

Purpose: Acute necrotic esophagus is an extremely rare condition characterized by circumferential ischemia of the esophagus. Full thickness necrosis only occurs in 7% of cases. Management often includes proton pump inhibitors, sucralfate, and in severe cases, an esophagectomy. Case Description: A 58-yearold man with history of diabetes presented to the emergency room having been found unconscious at home. He went into pulseless electrical activity cardiac arrest with return of spontaneous circulation after 10 minutes of cardiopulmonary resuscitation. He was intubated and started on norepinephrine. He was found to be in diabetic ketoacidosis with an anion gap of 25 and glucose over 1000. He developed positive troponins with ST elevations in V1-V5 on electrocardiogram. He was transferred to a tertiary medical center for cardiac catheterization. Upon transfer, the patient was found to be in severe septic rather than cardiogenic shock requiring epinephrine, norepinephrine, vasopressin, and phenylephrine. He was also in acute respiratory distress syndrome and anuric renal failure. He had minimal neurologic function secondary to large watershed ischemic strokes. Bilateral thoracenteses revealed 4L of cola-colored fluid. Pleural fluid analysis was exudative with a pH of 8.2 and amylase of 756. Serum amylase was 522. Gastric lavage returned similar cola-colored fluid. Computed Tomography demonstrated pneumomediastinum and a collection around the esophagus with air-fluid levels. Esophagogastroduodenoscopy revealed friable, grey/black esophageal mucosa extending from the cricopharyngeus to the gastroduodenal junction and was most concentrated in watershed regions. There were multiple areas of perforation. Bilateral chest tubes were placed for continued drainage of fluid. Vancomycin, piperacillin/tazobactam, and fluconazole were initiated. Given the extent of necrosis and critical nature of the patient, neither esophageal stenting nor esophagectomy could be performed. Once weaned off pressor support, the patient underwent a tracheostomy, esophagostomy drainage of distal esophagus, exclusion of esophagogastric junction with stapler, draining gastric tube, and feeding jejunal tube placement. Discussion: This case demonstrates a rare condition of acute esophageal necrosis complicated by esophageal perforation secondary to cardiac arrest in the background of severe diabetic vasculopathy and ketoacidosis. Given the critical nature of the patient, traditional esophagectomy could not be performed. A combination of esophagostomy creation and drainage placements allowed the patient to stabilize and eventually be discharged to a vent facility.