P2471 - Black Esophagus, Upside-Down Stomach and Cameron Lesions: Complications of a Large Hiatal Hernia

Smit S. Deliwala, MD¹, Murtaza S. Hussain, MD¹, Anoosha Ponnapalli, MD¹, Nikita Theophilus, MD¹, Harini Lakshman, MD¹, Lalida Kunaprayoon, MD¹, Sherry Demian, MD¹, Thulasi Beere, MD¹, Mamoon Elbedawi, MD, FACG¹, Grigoriy Gurvits, MD, FACG^2
1Michigan State University at Hurley Medical Center, Flint, MI; ²New York University School of Medicine, New York, NY

Introduction: Acute esophageal necrosis (AEN) is an emerging cause of gastrointestinal bleeding with an increasing incidence over the past two decades. It appears as a circumferential necrotic lesion encircling the distal esophagus with various proximal extensions. It is most commonly associated with exacerbations of medical co-morbidities such as diabetes, renal failure, coronary disease; however cases of AEN due to mechanical alteration in gut anatomy are exceedingly rare and its prognosis is less defined. We present a unique constellation of AEN, Cameron ulcers (CU), and gastric volvulus from a large paraesophageal hiatal hernia.


Case Description/Methods: A 77-year-old female began experiencing abdominal pain and repeated emesis. She had a history of COPD, GERD, episodes of bleeding ulcers, hiatal hernia, malnutrition, and recently COVID-19. She was hemodynamically stable, ill-appearing with tenderness to abdominal palpation and a negative stool guaiac. BP 106/48 mm/Hg, HR 107, requiring oxygen. Investigations revealed WBC 18.5 k/uL, Hgb 9.8 g/dL, and acute renal failure. A CT abdomen revealed complete herniation of the stomach into the posterior mediastinum, dilated esophagus, organoaxial gastric volvulus, and gastric distension [Figure 1 - Pane A-C]. IV fluids, pantoprazole 80 mg, and ondansetron 4 mg were given. An EGD revealed a large hiatal hernia, Cameron ulcers (CU), and necrotic ulceration along the mid-to-lower third of the esophagus. The patient deferred surgical intervention and was discharged home on hospice.

Discussion: These constellations represent a common underlying pathophysiologic mechanism that stems from large hiatal hernias and their effect on surrounding structures in our case, precipitated by a paraesophageal hiatal hernia that became too large causing acute gastric volvulus. In severe presentations, the stomach may herniate into the posterior mediastinum known as an upside-down stomach requiring surgery while CU represents trauma to the mucosa from the hernia sliding. In our patient, lower esophagus blood flow traversing through the lesser gastric curvature may have been compromised during gastric necrosis. Simultaneously, sudden gastric stunning from acute outlet obstruction can lead to prolonged acidic bathing of the esophageal mucosa. Often the esophagus can compensate for this by increasing blood flow, however, this is compromised in low-flow states. Limitations of our study include lack of follow-up. A systematic review of all cases of AEN and gastric volvulus are in table 1.


Figure: Figure 1: Pane A - Computed Tomography (CT) of the Abdomen revealing complete herniation of the stomach into the posterior mediastinum, with dilated esophagus and gastric distension. Pane B - Esophagogastroduodenoscopy (EGD) demonstrating Cameron ulcers (arrowhead). Pane C - EGD revealing necrotic lesions along the esophageal lumen consistent with Acute Esopahgeal Necrosis/Black Esophagus.

Table: Table 1 - Summary of previous cases of acute esophageal necrosis (AEN) associated with gastric volvulus and hiatal hernias amongst the literature


Disclosures:
Smit Deliwala indicated no relevant financial relationships.
Murtaza Hussain indicated no relevant financial relationships.
Anoosha Ponnapalli indicated no relevant financial relationships.
Nikita Theophilus indicated no relevant financial relationships.
Harini Lakshman indicated no relevant financial relationships.
Lalida Kunaprayoon indicated no relevant financial relationships.
Sherry Demian indicated no relevant financial relationships.
Thulasi Beere indicated no relevant financial relationships.
Mamoon Elbedawi indicated no relevant financial relationships.
Grigoriy Gurvits indicated no relevant financial relationships.


Smit S. Deliwala, MD¹, Murtaza S. Hussain, MD¹, Anoosha Ponnapalli, MD¹, Nikita Theophilus, MD¹, Harini Lakshman, MD¹, Lalida Kunaprayoon, MD¹, Sherry Demian, MD¹, Thulasi Beere, MD¹, Mamoon Elbedawi, MD, FACG¹, Grigoriy Gurvits, MD, FACG². P2471 - Black Esophagus, Upside-Down Stomach and Cameron Lesions: Complications of a Large Hiatal Hernia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.