S2039 “Black Esophagus”: A Rare Complication of Diabetic Ketoacidosis

Abstract

INTRODUCTION: Acute esophageal necrosis (AEN), also known as “black esophagus”, is a rare presentation of severe esophageal injury. Most cases occur in patients with cardiovascular comorbidities and alcohol use. Injury results from a combination of ischemic injury and gastroesophageal acid reflux-mediated mucosal damage. Hallmark endoscopic findings are a circumferential black mucosal discoloration which abruptly stops at the gastroesophageal junction. We report a case of black esophagus in a patient who presented with diabetic ketoacidosis (DKA). CASE DESCRIPTION/METHODS: A 62 year old male with poorly controlled diabetes mellitus presented with altered mental status after being found down with a reported episode of coffee-ground emesis. He was hypotensive on admission and was oriented only to self. Labs were significant for leukocytosis and multiple metabolic derangements including hyponatremia, hyperkalemia, acidosis, acute kidney injury, and hyperglycemia with a blood glucose of 1,878 mg/dL. He was admitted for hypovolemic shock secondary to DKA and was treated with vasopressors briefly, fluid resuscitation, and insulin. After resolution of DKA, he reported persistent dysphagia, epigastric pain, and nausea. Upper endoscopy was performed which showed friable circumferential black mucosal discoloration throughout the entire esophagus that spared the gastroesophageal junction. He was diagnosed with AEN and continued on a proton-pump inhibitor and sucralfate with improvement in symptoms. Repeat upper endoscopy was performed four weeks after discharge at which time the patient was endorsing recurrent dysphagia, epigastric pain and nausea. Upper endoscopy revealed a tight stricture in the mid esophagus requiring dilation. DISCUSSION: AEN is a rare clinical entity, with an estimated incidence of 0.01%. Our patient developed AEN likely due to profound hemodynamic compromise in the setting of DKA. Due to its relatively limited blood supply, the distal esophagus is preferentially affected, while findings of pan-esophageal involvement is less common. AEN carries a mortality rate of 23-35% and can be complicated by superimposed infection, esophageal rupture, and stricture formation. While data is limited, the mainstay of therapy involves identifying and treating the underlying disease and supportive care to allow for mucosal healing. Given its high mortality rate, AEN must be considered and accurately diagnosed. Repeat endoscopy should be done to demonstrate healing due to the risk of complications.Figure 1.: Endoscopic evidence of “black” mucosa with associated esophagitis.Figure 2.: Endoscopic image showing mucosal sparing of the GE junction.Figure 3.: Repeat endoscopy 4 weeks later with tight stricture in mid-esophagus.