Management of acute esophageal necrosis syndrome

Abstract

FIGURE 1. Endoscopic view of distal esophagus taken immediately before surgical correction of hiatal hernia. Photograph demonstrates circumferential necrotic appearing mucosa. CLINICAL SUMMARY A 62-year-old woman with a history of gastroesophageal reflux disease and hiatal hernia was seen by her gastroenterologist after 4 days of nausea, coffee ground emesis, and lower retrosternal chest pain. An esophagogastroduodenoscopy revealed a large hiatal hernia and necrotic mucosa in the distal half of the esophagus. The patient was resuscitated with intravenous fluids, a nasogastric tube was placed, and she was started on an empiric course of broad-spectrum antibiotics before being transferred to our institution for an impending surgical emergency. On arrival, the patient was afebrile, had normal vital signs, and was no longer reporting chest pain. She did not have a leukocytosis. Because of her stable clinical condition, the patient was observed while being treated with broad-spectrum antibiotics and a proton pump inhibitor for 4 days before an elective operation. Endoscopy confirmed ischemic changes starting 25 cm from the incisors and ending abruptly at the gastroesophageal junction (Figure 1). The outer esophagus and stomach appeared normal, with the exception of a shortened esophagus. A laparoscopic Nissen fundoplication was therefore performed over a 56F bougie with a concomitant esophageal lengthening procedure. The patient’s recovery was uneventful. She was observed in the hospital 4 days postoperatively while receiving a soft mechanical diet. Before discharge, she underwent a surveillance esophagogastroduodenoscopy, which revealed early healing of the distal esophageal mucosa (Figure 2). This patient returned to the clinic 3 weeks later, at which time she denied any recurrent episodes of emesis or of abdominal or chest pain.