S2451 Acute Esophageal Necrosis: A Rarely Encountered Clinical Entity

Abstract

Introduction: Acute Esophageal Necrosis (AEN), otherwise known as black esophagus for its remarkable appearance during endoscopy, is a rather rare entity in the gastroenterology field. Case Description/Methods: A 51-year-old male with a past medical history of diabetes complicated by peripheral neuropathy presented to the hospital with left lower extremity swelling and pain after a fall. On admission he underwent lower extremity x-ray with subcutaneous air concerning for necrotizing fasciitis. He was taken emergently to the operating room where he underwent 3 compartment exploration with irrigation and drain placement. On day 7 of hospitalization he developed persistent nausea and vomiting for which we were consulted. The following morning he was taken to the endoscopy suite. He was noted to have circumferential black appearance of the esophagus from 28 to 40 cm with abrupt transition to normal-appearing gastric mucosa at the GE junction. This was endoscopically consistent with acute esophageal necrosis He was placed on high-dose intravenous proton pump inhibitor (PPI) therapy as well as sucralfate suspension. Transfer was facilitated to a tertiary care center where repeat endoscopy confirmed the diagnosis. He had a gastrostomy tube placed and ultimately underwent repeat endoscopy 8 weeks later at the same tertiary care center which revealed severe benign appearing esophageal stricturing with inability to pass adult endoscope. It was recommended to continue on PPI therapy with repeat endoscopic evaluation with possible dilation the following month. Unfortunately, in the meantime the patient expired due to unknown causes (Figure). Discussion: AEN is defined by a circumferential, necrotic appearance that almost always affects the distal esophagus with abrupt cessation of the black contour at the GE junction. Incidence is 0.28%, affects men over 4 times more often than women with a mortality near 32%. AEN is usually multifactorial and affects people with many comorbidities. Presenting symptoms varied greatly, with the most prevalent being hematemesis (34%). Injury is related to esophageal ischemia and topical injury. AEN is almost always diagnosed by endoscopy. Biopsy can rule out other similarly appearing pathologies. Management of AEN typically involves treating the underlying cause. Empirical treatment includes IV fluids, PPI, sucralfate, NPO, and TPN in patients with poor nutritional status after 24 hours.Figure 1.: Multiple images showing diffuse esophageal necrosis with abrupt transition to normal mucosa at the GE junction.