Case Western Reserve University, University Hospitals Cleveland Medical Center Cleveland, OH, United States
Aya Tabbalat, MD1, Rawaa K. Alnabulsi, MBBS2, Elie S. Al Kazzi, MD, MPH2, Linda Cummings, MD, MS, FACG3 1Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH; 2University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH; 3University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Introduction: Acute Esophageal Necrosis (AEN) is a rare condition that presents with an upper gastrointestinal bleed. It is characterized by blackened esophageal mucosa usually affecting the distal esophagus. Etiology of AEN remains unclear; however, it has been proposed to result from an inciting ischemic injury to the esophagus, which is further aggravated by acidic gastric contents.
Case Description/Methods: A 56-year-old male with no medical history presented to the hospital with a 2-day history of abdominal pain associated with fevers, chills, night sweats, and loss of appetite. The patient reports a one month history of weight loss and fatigue. On presentation, he had an acute onset of coffee ground/black emesis. Vital signs revealed a respiratory rate of 25 breaths/min and were otherwise normal. Physical exam was notable for jaundice, distended abdomen and diffuse tenderness with no peritoneal signs. Laboratory testing was significant for white blood count of 24.3 x109/L, hemoglobin 11.5 g/dL, platelet count 116 x109/L, potassium 5.2 mEq, BUN 88 mg/dL, creatinine 2.61 mg/dL, AST 215 IU/L, ALT 632 IU/L, ALP 494 IU/L, direct bilirubin 5.5 mg/dL, INR 2.0, uric acid 12.9 mg/dL, lactate 11.5 mmol/L. CT scan of the chest, abdomen, and pelvis demonstrated mediastinal and hilar lymphadenopathy, hepatomegaly, ascites, multiple liver lesions, and numerous sclerotic bone lesions concerning for metastases. Serum tumor markers were elevated (carcinoembryonic antigen 793, cancer antigen 19-9 27,414). An EGD revealed severe esophagitis with blackened mucosa in the middle third and distal esophagus without stigmata of a recent bleed and a distal esophageal mass (figure 1 and 2). Brush cytology of the distal esophageal mass showed atypical epithelioid cells suggestive of malignancy. Liver biopsy showed poorly differentiated adenocarcinoma. The patient’s condition deteriorated and he passed away in the setting of multi-organ failure.
Discussion: AEN has been associated with underlying malignancy, infections, broad spectrum antibiotic use, gastric volvulus, paraesophageal hernia, hyperglycemia, diabetic ketoacidosis, Stevens-Johnson syndrome, cocaine use, alcoholic hepatitis, and lactic acidosis. Diagnosis is usually incidental in patients undergoing EGD for evaluation of an UGIB. Mortality rates range from 13% to 35%, with a case-fatality rate of 6% typically secondary to the underlying disease. In our case, the patient had an underlying malignancy likely triggering the occurrence of AEN.
Figure: Figure 1: Evidence of necrotic mucosa in the middle third of the esophagus. Figure 2: Necrotic mucosa and mass in the distal esophagus.
Disclosures: Aya Tabbalat indicated no relevant financial relationships. Rawaa Alnabulsi indicated no relevant financial relationships. Elie Al Kazzi indicated no relevant financial relationships. Linda Cummings indicated no relevant financial relationships.
Aya Tabbalat, MD1, Rawaa K. Alnabulsi, MBBS2, Elie S. Al Kazzi, MD, MPH2, Linda Cummings, MD, MS, FACG3. P2468 - A Curious Case of Jet Black Emesis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.