S4270 Diabetic Ketoacidosis Complicated by Esophageal Perforation: A Case Report of “Black Esophagus”

Introduction: Esophageal necrosis aka “Black esophagus” is a rare and life-threatening complication of diabetic ketoacidosis (DKA). It can also arise in the setting of other decompensated states, such as major surgery, trauma, thromboembolic phenomenon, septic shock, and alcohol intoxication. The pathophysiology involves ischemic injury to the esophageal mucosa due to hypovolemia, increased reflux of gastric contents and acidemia. Diagnosis is established by direct visualization during endoscopy. Biopsy is not required but can be supportive. Case Description/Methods: We present a case of a 50-year-old woman with insulin-dependent Type 2 diabetes, HLD presented to our emergency room with complaints of nausea, vomiting, lethargy, confusion and abdominal pain. Upon presentation, patient was hypotensive (BP 89/36 mmHg), tachycardiac (HR 135) and hypothermic (T 33.5). Other notable labs were serum glucose 750 md/dL and a WBC of 43k, anion gap of 32 and pH 6.9. Patient was managed with fluid resuscitation and IV antibiotics. Patient developed hematemsis following multiple episodes of vomiting. She underwent esophagogastroduodenoscopy that revealed diffuse circumferential esophageal necrosis, 24 cm from the incisors to the gastroesophageal junction. No active signs of bleeding was noted, though there was mild gastritis. No endoscopic intervention was undertaken. Given severity of necrosis, no biopsies were taken due to the high risk of perforation. She was kept on liquid diet, intravenous proton pump inhibitor, sucralfate, liquid diet for esophageal necrosis. Patient’s labs and symptoms started to improve with those measures. She was discharged home on a soft diet 5 days after her presentation. At 4-month follow-up, patient was tolerating a regular diet with minimal to no symptoms. Discussion: Esophageal necrosis carries a high mortality rate (up to 39%) and is typically seen in chronically ill patients with uncontrolled comorbid medical conditions. Outcomes may be improved by prompt resolution of hemodynamic compromise, and correction of underlying medical conditions. In our patient’s case, achieving glycemic control, resolution of DKA was key to recovery. Though rare, esophageal necrosis should be considered as a differential for patients presenting with DKA/HHS and hematemesis.