S3413 Cholangioscopy Through the PTC Route: Suddenly I See

Abstract

INTRODUCTION: Black esophagus is a rare endoscopic finding caused by acute esophageal necrosis (AEN). Studies suggest the incidence of AEN is less than 1%. We describe a case of a patient presenting with coffee ground emesis and black esophagus. CASE DESCRIPTION/METHODS: A 60-year-old male with a past medical history of HIV on HAART (CD4 count of 399 and undetectable VL), alcohol abuse, ESRD, DMII and HTN presented to the ED for intermittent hematemesis. The patient described several episodes of coffee ground emesis associated with worsening abdominal distention, pain and diarrhea. Two days prior, he was discharged from another hospital after being treated for the same condition, however EGD was not performed. His surgical history was significant for G-tube placement, one year prior. He was afebrile and hemodynamically stable. His abdomen was soft, distended, non-tender with normal BS. His rectal exam revealed melena. Initial labs were significant for a leukocytosis of 15.4 K/uL, Hg of 8.2 (MCV 83), Platelets 373, INR 1.3 and lactate of 1.8. CT demonstrated distal esophageal wall thickening, suggestive of esophagitis. EGD confirmed esophagitis with eschar (LA Grade D) at the mid and distal esophagus (45 cm from the incisors.) There was no extension of the lesion beyond the GE junction. No blood, clots or old heme was seen in the stomach. However, multiple non-bleeding clean base ulcers (Forrest Class III) were visualized in the duodenum. The patient's hematemesis was caused by acute esophageal necrosis. The patient was treated with fluid resuscitation and intravenous proton pump inhibitors. The patient declined further workup. He was discharged to a skilled nursing facility with plan for repeat upper endoscopy in 4-6 weeks. He declined repeat endoscopy. DISCUSSION: The pathogenesis of AEN is not fully understood however poor vascular perfusion may be a contributor. AEN manifests in the distal portion of the esophagus and frequently coexists with duodenal pathologies. Treatment begins with nil-per-os (NPO) restriction, intravenous proton pump inhibitors, fluid resuscitation and treatment of underlying medical comorbidities. Follow-up upper endoscopy is recommended in 4–6 weeks. Although uncommon, clinicians should consider AEN when evaluating patients with an upper GI bleed, as early recognition and prompt treatment may improve outcomes. Further studies are needed on treatment outcomes and survival when multiple comorbidities coexist.