S2421 A Dark Omen: Acute Esophageal Necrosis Associated With COVID-19

Abstract

Introduction: Black esophagus, also known as acute esophageal necrosis (AEN), is a rare clinical entity with an estimated prevalence of 0.01 to 0.28 percent of cases in endoscopy series. It can present with striking endoscopic findings characterized by diffuse circumferential black discoloration of the esophagus terminating at the gastroesophageal (GE) junction. It is mostly associated with tissue hypoxia due to low flow vascular states and corrosive injury in the setting of severe illness. Patients typically present with gastrointestinal bleeding. We present a rare case of a black esophagus in the setting of severe Coronavirus-19 (COVID-19) infection. Case Description/Methods: A 75-year-old male with diabetes and chronic kidney disease presented after a mechanical fall with a prolonged down time of 13 hours. He was found to have acute on chronic renal failure with rhabdomyolysis. He was initially stable however later developed respiratory failure from COVID-19 requiring steroids and ultimately ventilator support. His course was further complicated by new onset atrial fibrillation for which he received anticoagulation, worsening renal function requiring hemodialysis and significant hypotension requiring vasopressor support. In the intensive care unit, patient was noted to have melena with a significant drop in hemoglobin, he underwent an esophagogastroduodenoscopy which showed diffuse continuous black discoloration of the esophageal mucosa with abrupt transition at the GE junction consistent with black esophagus with multiple ulcers in stomach and duodenum (Figure). Patient was kept on IV proton pump inhibitors and anticoagulation was discontinued. Given worsening multiorgan failure, he was transitioned to comfort measures only and passed away the next day. Discussion: Black esophagus or AEN is a rare but concerning finding on endoscopy which must be recognized early and managed aggressively in order to improve clinical outcomes. In our patient AEN was likely due to a combination of hypoperfusion and hypoxia in the setting of severe COVID-19 infection with multiorgan failure. AEN could be seen more frequently in patients with severe COVID-19 infections who are frequently anticoagulated due to the associated prothrombotic state with increased risk of GI bleeding. It is important for physicians to be aware of AEN as a possible etiology of GI bleeds in these patients.Figure 1.: 'Black esophagus' - Acute esophageal necrosis.