S4648 Black Esophagus: A Unique Cause of Hematemesis

Introduction: Acute esophageal necrosis (AEN), aka “black esophagus”, is an extremely rare cause of upper gastrointestinal bleeding, with reported incidence as low as 0.06%. It is typically diagnosed during emergency esophagogastroduodenoscopy (EGD), characterized by diffuse, circumferential black epithelia with sharp demarcation at the gastroesophageal junction. Patients may present with dysphagia, nausea, hematemesis, epigastric pain, and syncope. Common risk factors described are alcohol use disorder, hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease and those in hemodynamic compromise, such as sepsis, shock, or multiorgan failure. Management includes maintaining the patient nil-per-os (NPO), hemodynamic stabilization, IV proton pump inhibitors (PPI), and correcting the precipitating factor. Below we present the case of a 72-year-old woman who presented with AEN. Case Description/Methods: A 72-year-old woman with a prior medical history of alcohol use disorder presented after being found down by her neighbor with blood around her mouth. She was transferred to the emergency room where she had a witnessed 1L hematemesis, subsequently aspirated, and was emergently intubated for airway protection. Broad spectrum antibiotics were initiated for concern of spontaneous bacterial peritonitis (SBP). She was started on high dose norepinephrine drip and octreotide drip, when she then developed ventricular fibrillation and was cardioverted twice. computed tomography of the abdomen demonstrated severe fatty liver disease and pancreatitis. Her initial hemoglobin was 11 g/dL which dropped to 6 g/dL; she was given massive transfusion protocol. She was started on pantoprazole drip and taken to the intensive care unit where emergent bedside EGD demonstrated diffuse necrosis throughout the esophagus, consistent with AEN. Despite aggressive measures, our patient expired on hospital day 3. Discussion: While AEN is a rare cause of hematemesis, clinicians must remain alert and initiate management immediately. AEN management includes aggressive hemodynamic resuscitation, intravenous proton pump inhibitor therapy, and treatment of underlying processes. Common complications include esophageal perforation, mediastinitis, and death, with a reported mortality ranging from 12.5% to 32% of all patients, although this is typically related to the underlying condition causing AEN rather than AEN itself. Following resolution of the acute critical illness, most patients experience resolution of necrosis with conservative management, with up to 25% developing esophageal strictures which may require repeated endoscopic dilations.