Shannon L. Tosounian, DO, Ronald Miick, MD, James Walter, MD
Albert Einstein Medical Center, Philadelphia, PA
Introduction: Acute Esophageal Necrosis (AEN) is a rare condition characterized by diffuse circumferential necrosis of esophagus. The majority of cases have no identified etiology, but risk factors that may lead to hypoperfusion (thromboembolic events, sepsis, trauma, vasculopathy) are typically present. We present the case of a woman with decompensated cirrhosis presenting with hematemesis and endoscopic findings of AEN.
Case Description/Methods: A 66-year-old female with cirrhosis secondary to alcohol abuse complicated by ascites presented from home due to witnessed hematemesis. History was limited due to patient’s mental status. Upon initial examination her blood pressure was 128/53 mmHg, heart rate of 118 bpm, Sp02 of 84%. On examination she appeared lethargic and in mild distress with dried blood in her oropharynx. Her abdomen was soft but distended. Laboratory results included: WBC 24.0 103/mcL, Hemoglobin 4.9g/dL, Platelets 234 103/mcL, INR 2.7, and lactic acid 4.18 mmol/L. A chest X-ray showed bilateral pleural effusions. She was started on pantoprazole and octreotide drips, ceftriaxone, and two units of packed red blood cells. She was taken emergently for upper endoscopy due to concerns for variceal hemorrhage. The entire lumen of the esophagus extending from the incisors to top of gastric folds was black and necrotic-appearing circumferentially (Figs 1-2) . Biopsies were obtained (Fig 3). Type 2 gastroesophageal varices, medium in diameter with no bleeding were found in the gastric fundus. She was placed on broad spectrum antibiotics and admitted to medical ICU. The following day she had increased O2 requirements secondary to acute respiratory distress syndrome and required intubation. She became hemodynamically unstable requiring vasopressors, then developed an acute kidney injury requiring continuous renal replacement therapy. Due to declining clinical status, she was made comfort care and ultimately expired on Day 4 of admission. Esophageal pathology demonstrated necrotic esophageal mucosa with acute and chronic inflammation.The etiology of her necrotic esophagus remains unclear.
Discussion: AEN is a rare diagnosis associated with low perfusion state with an estimated 32% mortality rate . It is associated with liver dysfunction in approximately 15% of cases, as in our patient. Early recognition and supportive care is crucial for survival, and further studies are needed to better understand etiology and management of AEN.
Citation: Shannon L. Tosounian, DO, Ronald Miick, MD, James Walter, MD. P0308 - ACUTE ESOPHAGEAL NECROSIS IN PATIENT WITH DECOMPENSATED CIRRHOSIS. Program No. P0308. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.