S4322 Acute Esophageal Necrosis in Critical Illness: Insights From a Case Series of Ischemia and Multi-Organ Dysfunction

Introduction: Acute esophageal necrosis (AEN), or “black esophagus,” is a rare, life-threatening condition often seen in critically ill patients with cardiovascular disease, hypotension, and/or multi-organ dysfunction. It presents as blackening of the esophageal mucosa, typically at the distal esophagus, and is associated with melena, hematemesis, and signs of hypoperfusion. With a 32% mortality rate, early diagnosis and supportive care (e.g., total parenteral nutrition, intravenous proton pump inhibitors) are crucial. Case Description/Methods: Patient A: A 70-year-old man with severe comorbidities developed acute-on-chronic renal failure, respiratory failure, and AEN. Endoscopy revealed circumferential necrosis from mid to distal esophagus, likely due to ischemia and impaired mucosal repair. Despite supportive care, the patient died. Patient B: An 84-year-old man developed AEN after coronary bypass surgery, presenting initially as melena. Endoscopy showed diffuse esophageal necrosis and duodenal ulcers. He required multiple endoscopies and embolizations for gastrointestinal bleeding but healed after interventions and was eventually discharged. Patient C: A 69-year-old woman with acute pancreatitis and hypoxemic respiratory failure developed AEN due to esophageal hypoperfusion. Managed with proton pump inhibitors and total parenteral nutrition, she showed mucosal healing and was able to be discharged. Discussion: This case series highlights the varied clinical presentations and outcomes of AEN. While AEN typically shows a sharp transition between viable gastric mucosa and necrotic esophageal tissue, Patients B and C exhibited unusual findings, including rapid healing of esophagitis without persistent necrosis, suggesting the potential for quicker recovery with supportive care. Patient A, with severe comorbidities and systemic failure, experienced a fatal outcome due to multi-organ dysfunction and ischemia. In contrast, Patients B and C, despite severe presentations, recovered with appropriate interventions. This suggests that early diagnosis and management can improve outcomes, particularly in patients with fewer comorbidities.