S4258 The Vanishing Esophagus: A Case of Acute Esophageal Necrosis

Introduction: Acute Esophageal Necrosis (AEN) is a rare entity and medical emergency with an incidence of 0.01%-0.28%. The 2-hit hypothesis for AEN proposes that 2 events, an initial low-flow vascular state followed by a secondary injury, contribute to the development of this condition. Case Description/Methods: Case of a 70-year-old man former smoker with medical history of hypertension, atrial fibrillation and coronary artery disease who presented to the emergency department after 4 days of blood-streaked oral secretions associated to epigastric discomfort. Examination showed bradycardia and epigastric tenderness. Blood work was remarkable for lactatemia. Hemoglobin levels were within patient`s baseline and there was no elevation on BUN to Creatinine ratio. Computed tomography of the abdomen and pelvis with intravenous and oral contrast showed thickening of distal esophagus. Patient was started on high dose proton pump inhibitor and evaluated by the GI Inpatient team. Upper endoscopy revealed severe deep ulceration of the mid to distal esophagus with friable mucosa and some necrotic tissue. Gastroesophageal junction was spared. Endoscopic findings were consistent with acute esophageal necrosis. During admission medication for rate control was optimized with resolution of bradycardia. He was discharged home with high dose proton pump inhibitor for 8 weeks. After completion of therapy, a follow up upper endoscopy revealed normal esophageal mucosa with complete resolution of necrotic esophagitis. Discussion: In this case, AEN is suspected to be secondary to a decrease in esophageal perfusion caused by hemodynamic compromised in a patient with risk factors for vascular disease. Despite no biopsy proved diagnosis, endoscopic findings including inflammation in distal esophagus with the sparing of the gastroesophageal junction supports the diagnosis of esophageal ischemia in this patient. It is important to suspect and recognize this condition as a possible etiology of gastrointestinal bleeding since it is a rare cause that carries a high mortality rate.