S2034 An Uncommon Cause of Chest Pain: Acute Esophageal Necrosis

Abstract

INTRODUCTION: Acute esophageal necrosis (AEN) is a rare but important cause of hematemesis, melena, dysphagia, and chest pain typically seen in patients with vascular disease in which esophageal necrosis circumferentially embodies the esophagus with GEJ (gastroesophageal junction) sparing. We present the case of chest pain and hematemesis secondary to AEN. CASE DESCRIPTION/METHODS: A 70-year-old male with ESRD, DM, prior CVA on Eliquis, with altered mental status, hypotension, neck, back, and chest pain. In the ED, he was hypotensive 67/51mmHg, and had coffee ground emesis. Hemoglobin decreased from 9.9 to 7.1g/dL requiring blood transfusions, PPI drip, and ICU admission. Upper endoscopy demonstrated diffuse, severe mucosal necrosis with black necrotic tissue in the middle and lower thirds of the esophagus (Figure 1, 2), but with normal tissue and sparing of the GEJ (Figure 3). A percutaneous gastrojejunostomy tube was placed. The patient had clinical improvement, but expired after a prolonged hospital course. DISCUSSION: Acute Esophageal Necrosis is a rare endoscopic finding defined by diffuse, circumferential black mucosa that spares the GEJ. More common in older males, and associated with heart failure, atherosclerosis, diabetes, renal failure, and cancer, its etiology remains uncertain though may be from severe underlying chronic disease, progressive vascular insufficiency, reduced mucosal barriers, and gastric regurgitation. Due to less blood, this pathology starts in the distal third of the esophagus, progressing proximally. The GEJ is spared due to increased vasculature. Though a rare cause of chest pain, it is important to consider AEN due to its significant complications of perforation and stricture and high mortality rate. Currently, there are no guidelines for management, though esophageal rest, intravenous fluids, and improved nutrition via PEG-J tube or parenteral nutrition are generally sought after. Though rare, AEN should be considered in patients with severe chest pain due to its significant complications and a high mortality rate, and further studies are needed to aid in management to improve patient outcomes.Figure 1.: Diffuse, severe necrotic tissue encircling the esophagus.Figure 2.: Necrotic tissue circumferentially encompassing the esophagus.Figure 3.: Necrotic tissue of the distal esophagus with abrupt transition point with sparing of the GE junction.