S4260 Acute Esophageal Necrosis: Black Esophagus

Introduction: Across many medical disciplines, the word “necrosis” imbues a sense of urgency and highlights the gravity of a patient’s medical condition. From necrotizing fasciitis to necrotizing enterocolitis in infants, to osteonecrosis of the jaw, to acute esophageal necrosis (AEN), the rapid autolysis of various tissues is an ominous sign in these patients. Mortality from AEN, commonly known as “black esophagus”, is nearly 32%. It predominantly affects men 4 times more often than women and is usually a result of hypoperfusion or ischemia. Diagnosis is made endoscopically with the assistance of computed tomography scan and pathology. We present a rare condition of AEN that was diagnosed with esophagogastroduodenoscopy (EGD). Case Description/Methods: A 60-year-old man with past medical history of hypertension, type-2 diabetes, coronary artery disease, and gastroesophageal reflux disease presented with coffee ground emesis and melena. His symptoms started with nausea 2 days before the admission. He reported heavy alcohol use in the past but admitted to 2 drinks nightly on average. Vitals on admission were heart rate: 110/min, blood pressure: 85/50 mmHg, WBC: 18,500/mm3, Hb: 12 g/dl, platelets: 210,000/mm3, lactate: 18 mmol/L, and INR: 1.1. He was fluid resuscitated, started on proton pump inhibitor IV therapy and once stabilized, an EGD was performed, which showed an AEN from the level of the cricopharyngeal muscle to gastroesophageal junction. For concerns of vascular ischemia, a computed tomography-angiography was obtained but did not reveal vascular pathology. Discussion: At first glance, this patient presented typical signs of upper GI bleeding. However, EGD led to diagnosis of a rare condition of AEN. Ninety percent of the time, AEN can present with melena or hematemesis and can be accompanied by syncope, fever, abdominal pain and nausea. Endoscopically, the esophageal mucosa had a circumferential black color which immediately terminated at the gastroesophageal junction, usually indicative of a vascular compromise. Due to its anatomical location and vascular supply, distal esophagus is prone to be a ‘watershed’ region. This patient had risk factors for ischemic conditions such as history of coronary artery disease, hypertension, and diabetes along with septic presentation and low flow state due to acute blood loss. In such cases, while AEN might not be the first differential diagnosis for melena, index of suspicion should be in the differential and the supportive care as well as treating the underlying causes are important in management.