Traumatic Nasogastric Tube Placement Causing Acute Upper GI Bleeding in a Black Esophagus: A Warning to Gastroenterologists and Clinicians

Abstract

Acute necrotizing esophagitis (Black Esophagus) is a rare and sometimes fatal syndrome, typically affecting older males, with a prevalence of up to 0.01% of all endoscopy cases. In our tertiary referral center, we describe the case of a 57-year-old male with a history of hypertension, diabetes mellitus type II, and renal cell carcinoma who presented for an elective partial nephrectomy. His post-operative course was complicated by gross hematuria requiring multiple blood transfusions, and he was found to have a AV fistula and pseudoaneurysm of his kidney. He then developed fevers and hypotension and was found to have bacteremia and a urinary tract infection. On post-op day 12, the patient became obtunded and a nasogastric tube was placed which aspirated copious coffee-ground materials. Overnight, the patient had frank hematemesis and was transferred to the ICU; an emergent EGD was performed. Diffuse esophagitis with necrosis was found in the mid and distal esophagus (Image 1A). His nasogastric tube was removed, which unveiled a pulsatile arterial bleed 4 cm proximal to the GE junction (Image 1B). Hemostasis was achieved with BICAP cautery (Image 1D). He was made strict NPO, IV PPI was started, and antifungals were added. A follow up EGD on post-op day 14 demonstrated a sharp demarcation of normal healthy esophageal mucosa in the proximal esophagus to necrotic black esophagus distally (Image 2B). A final endoscopy was performed 6 days later, with the majority of esophagus demonstrating signs of healing (Image 2 C,D). Black esophagus is thought to be due to a “two hit” phenomenon, where an initial event such as a low flow vascular state predisposes the esophageal mucosa to severe topical injury from acid reflux. With concomitant gastric outlet obstruction, accumulation of gastric fluids results in direct tissue injury and necrosis of the esophageal mucosa, with the distal third of the esophagus being most vulnerable to ischemic injury due to its relative hypovascularity. This elusive diagnosis should not be missed in critically ill patients with hemorrhagic or septic shock who develop upper GI bleeding during their hospitalization. We recommend that before urgent nasogastric tube placement for gastric decompression, a bedside endoscopy should be considered to rule out acute necrotizing esophagitis, as placement of a foreign body in a severely diseased esophagus could lead to direct tissue injury and significant GI bleeding as was the case in our patient.1723_A Figure 1. Initial EGD A. Necrotizing Esophagitis (Black Esophagus) - B. Active arterial bleeding in distal esophagus from NGT trauma C. Large clot burden in esophagus D. NG trauma s/p BICAP treatment1723_B Figure 2. A, B. EGD #2 (48 hours later) - distal esophageal necrosis (A) with proximal sharp demarcation from necrotic esophagus to normal mucosa (B). C, D. EGD #3 (8 days after initial EGD) - healthy, healing esophageal mucosa with viable granulation tissue