Black Esophagus and Necrotic Duodenum Masquerading as New Onset GERD

Abstract

Background: Black esophagus is a rare finding of acute esophageal necrosis that was first described endoscopically in 1990 by Dr. Goldenberg. It is characterized by circumferential black esophageal mucosa in the distal portion of the esophagus, with an abrupt transition to normal mucosa at the gastroesophageal junction. Case Presentation: A 74 year-old obese male presented to his primary care physician for new onset epigastric burning pain. He was prescribed omeprazole once daily, which fully resolved his epigastric pain within one week. The patient self-discontinued omeprazole seven days later and had a rapid reoccurrence and worsening of his epigastric burning sensation. This prompted his decision to present to the Emergency Room. A CT abdomen/pelvis with oral contrast showed new moderate ascites and circumferential wall thickening at the distal esophagus and mid-jejunum. The EGD demonstrated an adherent circumferential white plaque from 22-25cm. In the distal 1/2 of the esophagus, there was a transition to diffuse black mucosa that continued to the GEJ. Within the distal half of the esophagus there were four large columns of varices without high risk stigmata. At the GEJ there was an abrupt conversion to normal appearing mucosa. Esophageal biopsies demonstrated ulcerated squamous mucosa with fungal organisms. Within the stomach there was moderate portal hypertensive gastropathy. The duodenal bulb had mild erythema but was otherwise normal. Starting in the duodenal sweep and extending to the 3rd portion of the duodenum there were several dozen scattered clean-based ulcers varying in size from 2-15mm. There were also one dozen eschar/necrotic lesions ranging 5-10mm and diffuse mucosal edema and erythema with easy tissue friability. Duodenal biopsies showed non-specific acute inflammation, negative for CMV, dysplasia, malignancy or amyloid. A MRI abdomen with IV contrast demonstrated intrahepatic portal vein thrombosis, as well as chronic thrombosis of the splenic vein and superior mesenteric vein. Esophageal and paragastric collaterals were present. The liver demonstrated subtle nodular contour. Discussion: Acute esophageal necrosis (AEN) is a rare endoscopic finding that manifests preferentially within the distal esophagus, often as a result of tissue ischemia. Duodenal bulb ulcers and erosions are not an uncommon finding in these patients. Our case is unique because of the simultaneous necrotic involvement within the 2nd and 3rd portion of the duodenum.1763_A Figure 1. Mid-Esophagus1763_B Figure 2. GEJ1763_C Figure 3. Duodenum, 2nd portion