Unusual Esophageal Presentation of Atherosclerosis of Thoracic Aorta

Abstract

Introduction: Ischemic changes can occur in almost any segment of the GI tract but ischemic necrosis of esophagus is uncommon. The upper, middle and lower third of esophagus are supplied by the inferior thyroid artery, thoracic aorta, and left gastric artery respectively. Case Report: A 74-year-old woman with a history of hypertension, hyperlipidemia and diabetes presented to emergency room (ER) after being found down with severe lethargy and pre-syncope. She had an episode of vomiting and complained of chest pain. Initial physical exam was non-contributory and laboratory data showed consistent elevation in troponin I levels and a hemoglobin of 9.1 g/dL. She was initially evaluated with a CT angiogram of the chest which showed no evidence of pulmonary embolism but revealed diffuse atherosclerotic calcification of thoracic aorta. Subsequently a coronary angiogram was performed which showed non-occlusive coronary artery disease. She was incidentally found to have a deep vein thrombosis (DVT) in right lower extremity and was started on low-molecular weight heparin. She was also started on aspirin and clopidogrel for her underlying coronary artery disease. One day after her discharge she presented to the ER with hematemesis, nausea, and epigastric pain. Aspirin, clopidogrel and heparin were discontinued and she was started on an intravenous pantoprazole infusion. Upper GI endoscopy showed necrotic and friable mucosa with oozing of blood noted in upper and middle third of the esophagus (Figure 1). Rest of the endoscopic exam was normal. Histopathology of random biopsies of mid-esophageal necrotic areas showed frank necrosis with inflammatory/reactive changes. Subsequently hematemesis resolved as she was placed on oral pantoprazole and sucralfate. IVC filter was placed for her underlying DVT and low dose aspirin was started on discharge.Figure 1Discussion: Atherosclerotic calcifications of the thoracic aorta can be indicative of ongoing ischemia of its esophageal branches which primarily supply the middle third and possibly lower part of upper onethird of the esophagus. A catheter based intervention like a coronary angiogram can dislodge atherosclerotic plaques which can potentially form atheroembolic occlusion of the esophageal branches of thoracic aorta leading to necrosis of primarily the middle third of the esophagus.