Scripps Clinic / Scripps Green Hospital La Jolla, CA
Pooja Magavi, MD1, Emem Udoh, MD, MBA2, Ahmad Mansour, MD2; 1Scripps Clinic / Scripps Green Hospital, La Jolla, CA; 2Scripps Clinic, La Jolla, CA
Introduction: Acute esophageal necrosis (AEN) is a rare condition with unclear etiology. Its name is derived from the characteristic endoscopic appearance of circumferential, black discoloration of the distal esophageal mucosa, ending abruptly at the gastroesophageal junction. Ischemic events have been identified as a precipitating factor. It is associated with significant morbidity and mortality, especially in patients with other underlying medical conditions, and can be complicated by esophageal stricture or perforation.
Methods: A 58-year-old female with end-stage renal disease secondary to reflux nephropathy on peritoneal dialysis presented for elective kidney transplant. She underwent a heterotopic cadaveric transplant and briefly required pressor support for peri-operative hypotension. Her course was further complicated by persistent nausea and vomiting, progressive to bloody emesis. She had a benign abdominal exam and CT scan was negative for acute pathology. Initial laboratory workup was unremarkable, apart from persistently low albumin (< 2.5 g/dL). Upper endoscopy revealed necrotic mucosa in the distal esophagus without active bleeding, representative of AEN (Figure 1). The patient was managed with bowel rest, IV Protonix, sucralfate and blood products to help stabilize her subsequent anemia. She clinically improved and was discharged on post-operative day 8. Endoscopy one month later showed normal esophageal mucosa (Figure 2). Discussion: AEN is a rare condition, with a prevalence of up to 0.2%. Affected patients have a mean age of 68 years and are more frequently male, unlike our patient. Low flow vascular states may predispose individuals to development of AEN, especially in conjunction with gastroesophageal reflux, and upper gastrointestinal bleeding is a common presenting sign, as in our patient. The characteristic pattern of esophageal involvement reflects the relative hypo-vascularity of the distal esophagus. Medical management should address underlying hypo-perfusion or ischemia, ongoing corrosive insults (i.e. gastric outlet obstruction with reflux) and impaired reparative or protective mechanisms (i.e. malnutrition). Our patient’s peri-operative hypotension and poor nutritional status likely put her at risk for AEN. Long-term, esophageal stricture is the most common complication of AEN. Mortality can result from esophageal perforation or complications from other medical issues. Nevertheless, as in our patient, supportive care frequently leads to clinical resolution.
Initial upper endoscopy showing circumferential, friable mucosa in the distal esophagus
Repeat endoscopy showing normal esophageal mucosa
Disclosures: Pooja Magavi indicated no relevant financial relationships. Emem Udoh indicated no relevant financial relationships. Ahmad Mansour indicated no relevant financial relationships.