S2278 Black Esophagus: A Striking Etiology of Gastrointestinal Bleeding

Abstract

Introduction: Black esophagus, or acute esophageal necrosis (AEN), is an uncommon etiology of upper gastrointestinal bleeding with incidence 0.01%-0.2% and poor prognosis. AEN is characterized by endoscopic findings of diffuse circumferential black discoloration of distal esophageal mucosa with sharp demarcation at the GEJ. The pathophysiology of AEN is unknown, however current hypotheses implicate ischemia, thromboembolic injury, critical illness, and corrosive injury. We describe a case of black esophagus in a patient with hemorrhagic shock. Case Description/Methods: An 83-year-old woman with hypertension presented to an outside hospital after a fall with lethargy, acute hypoxic respiratory failure, and shock. CT chest revealed right sided hemothorax. The patient was intubated, resuscitated with IV fluids and blood products, initiated on vasopressors, and a chest tube was placed prior to transfer to our institution. Repeat CT chest was concerning for the right thoracostomy tube traveling through the right middle lobe parenchyma and terminating within the mediastinum between the left atrium and the distal esophagus. The chest tube was removed and replaced in the operating room. Double contrast esophogram was without esophageal leak. The patient subsequently developed melena and worsening anemia. EGD demonstrated sharply demarcated circumferential black ulceration of the distal esophagus consistent with black esophagus without obvious signs of perforation. IV PPI and therapy aimed at reversing the underlying shock was pursued. Unfortunately, after a prolonged hospital course with worsening acute respiratory distress syndrome and inability to liberate from the ventilator, the patient’s family elected to pursue comfort measures and the patient expired (Figure). Discussion: In this case, AEN was most likely caused by ischemia secondary to hemorrhagic shock. Black esophagus carries a very poor prognosis, usually related to the underlying condition. Timely recognition of AEN and treatment aimed at reversing the underlying etiology can help prevent complications such as infection, esophageal stricture, and perforation. AEN is managed with aggressive IV PPI, NPO, and avoiding passage of nasogastric tubes due to risk of perforation. In rare instances, surgical intervention may be warranted. This case highlights the need to maintain a wide differential diagnosis for gastrointestinal bleeding and the importance of early recognition and treatment of this rare condition to prevent complications.Figure 1.: EGD indicating circumferential black ulceration of the distal esophagus with clear demarcation (arrow).