S3428 Septic Shock Causing Black Esophagus

Abstract

INTRODUCTION: Sepsis has the potential to change perfusion throughout the body. If sepsis is not appropriately managed it leads to significant end organ damage with shock. Often times when multiple organs are affected the mortality rates are exceptionally high. Multiple studies have shown early management with antibiotics, vasopressors, and source control lead to better outcomes for patients with septic shock [1]. Hemodynamic stability must be balanced with organ perfusion. A common manifestation of septic shock is often end organ ischemia. CASE DESCRIPTION/METHODS: A 65 year old male with a history of atrial fibrillation and recent right sided stroke presented for altered mental status and acute hypoxic respiratory failure. The patient was placed on a mechanical ventilator. Chest X-ray showed signs of aspiration pneumonia. He was admitted to intensive care with shock requiring vasopressors. He was placed on broad spectrum antibiotics for presumed sepsis. A NG tube was placed for enteral feeding. X-ray imaging confirmed placement of feeding tube. Despite aggressive care the patient’s vasopressor requirements kept worsening with deteriorating lactic acidosis. Renal and hepatic failure continued to worsen along with the patient’s acidosis. CT chest was performed to better visualize the pneumonia. Incidentally it revealed that the feeding tube had perforated through the distal esophagus at the level of the GE junction. Imaging was positive for extensive pneumomediastinum. The patient was taken for immediate EGD for endoscopic evaluation of his esophageal perforation. During endoscopy, it was noted that patient had circumferential esophageal ischemia and necrosis. His mucosa was noted be sloughing off into his intraluminal space. The patient continued to decline with worsening organ failure. An esophagectomy could not be performed. Instead, family opted to allow patient to pass with comfort measures. DISCUSSION: This patient presented with a rare complication of septic shock – acute esophageal necrosis (AEN). At times referred to as “black esophagus,” AEN is noted to have a mortality rate between 30-50% [3]. It often occurs at the distal portion towards the GE junction [4]. This is the same region at which our nasogastric tube perforated through this patient’s esophagus. Unfortunately when AEN is associated with perforation it has higher mortality. Perforations occur only about 7% of the time in AEN [5]. This case shows the rare complication of septic shock resulting in AEN with subsequent esophageal perforation.Figure 1.: Hydrothorax, Pneumothorax, Pneumomediastinum, & Air Surrounding Esophagus.Figure 2.: NG Tube Perforating GE Junction.Figure 3.: G Tube Terminating Outside GI Tract.