University of Arizona College of Medicine Phoenix, AZ
Paul Gomez, MD, Divya Patel, MD, Nael Haddad, MD, Anam Omer, MD, Sakolwan Suchartlikitwong, MD, Paul Muna-Aguon, MD, Layth Al-Jashaami, MD, Aaron Goldberg, MD; University of Arizona College of Medicine, Phoenix, AZ
Introduction: Acute esophageal necrosis (AEN), commonly referred to as “black esophagus”, is a rare condition of an unclear etiology that is characterized by the development of diffuse circumferential black discoloration of the esophageal mucosa. We present a case of AEN in an elderly male with multiple co-morbidities and typical risk factors associated with this rare condition.
Methods: 67-year-old male presented to our hospital with cough, nausea, and fatigue. Past medical history significant for gastroesophageal reflux disease, diabetes mellitus II, and polysubstance abuse. Patient denied emesis, dysphagia, odynophagia or caustic ingestion. Physical examination was notable for decreased right sided breath sounds, and right lower extremity erythema. Abdominal exam was normal. Initial labs showed WBC 33.6 K, lactic acid 3.43 mmol/L, glucose >565 mg/dL, serum ketones 2.96mmol/L, and anion gap 15 mEq/L. CT of chest and abdomen showed diffuse distal esophageal wall thickening. Subsequent EGD revealed diffuse black discoloration, exudates and ulcerations of the esophagus that abruptly stops at GE junction highly suggestive of AEN. Patient received treatment for cellulitis and DKA and was started on proton pump inhibitor and sucralfate suspension. After discharge, patient presented to Gastroenterology clinic and denied any reflux symptoms, dysphagia or odynophagia. Discussion: AEN is a rare syndrome with an unclear etiology. At present, the “two-hit” hypothesis remains the most accepted underlying pathophysiological mechanism. The first hit compromises an ischemic event causing initial damage to the esophageal mucosa, followed by a secondary insult, such as massive acid reflux resulting in esophageal necrosis. Most of patients present with upper GI bleeding along with dysphagia, epigastric or retrosternal chest pain. Patients may also have symptoms related to their underlying conditions including signs of sepsis, symptoms related to hyperglycemic states or symptoms related to an underlying malignancy. Endoscopically, AEN is characterized by development of diffuse, circumferential, black appearing friable esophageal mucosa that abruptly ends at GE junction. Biopsy is usually recommended but not required for diagnosis given classical endoscopic features. Treatment involves proton pump inhibitors and most importantly treating co-morbid conditions. The overall mortality of AEN approaches 32% and that is largely related to the underlying medical conditions and the overall health of the patient.
Disclosures: Paul Gomez indicated no relevant financial relationships. Divya Patel indicated no relevant financial relationships. Nael Haddad indicated no relevant financial relationships. Anam Omer indicated no relevant financial relationships. Sakolwan Suchartlikitwong indicated no relevant financial relationships. Paul Muna-Aguon indicated no relevant financial relationships. Layth Al-Jashaami indicated no relevant financial relationships. Aaron Goldberg indicated no relevant financial relationships.