Wright State University Boonshoft School of Medicine Dayton, OH, United States
Bahar Cheema, MD1, Drew Triplett, DO1, Fadi Odish, MD2 1Wright State University Boonshoft School of Medicine, Dayton, OH; 2Wright State University Boonshoft School of Medicine, Dayton,, OH
Introduction: Acute esophageal necrosis(AEN) is characterized by black esophageal mucosa likely due to tissue hypoperfusion, lack of defense barriers and increased acid reflux/exposure to gastric contents.The prevalence is 0.001 to 0.2%
Case Description/Methods: 86 year old male with hypertension, atrial fibrillation presented with abdominal pain, nonbloody emesis and diarrhea for 3 days.Vitals on admission were temperature 96 F, blood pressure 155/67 mm hg, heart rate 96 beats/min, respiratory rate 20/min, and O2 saturation 95% at room air. He was alert and had mild tenderness to palpation in the right upper quadrant of the abdomen. Labs showed total bilirubin 2.8, alkaline phosphatase 502,AST 137. Hemoglobin(Hb) was 9(at baseline), platelets 201,INR 1.2, WBC 9.1. MRI abdomen showed suspicion for acute cholecystitis, cirrhosis, liver lesions representing HCC with infiltrative mass in right lobe. AFP 193.1. On day 2, he had hematemesis and melena. Hb dropped from 9.4- 7.8 g/dL. IV Octreotide, IV Ceftriaxone, and PPI were started and he underwent EGD which showed black circumferential mucosa at 23 cm to the GE junction at 41 cm, no visible esophageal varices. The stomach was edematous and pale. Duodenum had two large 2 cm pigmented ulcers in the bulb and sweep, no active bleeding. His Hb remained stable and he was discharged with oral PPI and a 2 day course of Cefotetan after receiving IV antibiotics. Patient was readmitted four days later with fever 101.7 F, dyspnea and confusion. He was treated for acute on chronic hypoxic respiratory failure due to concern for hospital acquired pneumonia and fluid overload. C difficile test was negative. Lactulose was started. EGD biopsies during prior hospitalization were positive for Candida. He was started on fluconazole. Hospital course was complicated by severe encephalopathy, requiring intubation. Ultimately, palliative care was consulted, comfort measures were pursued and he passed away.
Discussion: This case highlights key characteristics of AEN:1) most common in men (4:1) ratio after the age of 60,2) associated with broad spectrum antibiotics and infections such as Candida albicans, CMV, HSV, Klebsiella pneumoniae 3) history of malignancy- 20%, 4) alcohol abuse-10%, 5) hypertension-20%. 70% of patients present with hematemesis.Treatment is focused on supportive care and addressing coexisting comorbidities. Although mortality is high (32%), it is not necessarily AEN that is the cause of mortality but rather the patient's comorbidities and underlying conditions.
Figure: Black esophagus
Disclosures: Bahar Cheema indicated no relevant financial relationships. Drew Triplett indicated no relevant financial relationships. Fadi Odish indicated no relevant financial relationships.
Bahar Cheema, MD1, Drew Triplett, DO1, Fadi Odish, MD2. P1414 - A Rare Predictor of Mortality: Black Esophagus, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
