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An elderly male with coronary artery disease as well as atrial fibrillation on rivaroxaban presented following a syncopal episode. Workup revealed acute non–ST-elevation myocardial infarction. Aspirin and clopidogrel were administered followed by coronary angiography. Twelve hours after his procedure, he developed delirium, fever, tachycardia, and hypotension. Urgent chest computed tomography revealed acute subsegmental pulmonary emboli for which heparin drip was initiated. Empiric antibiotics were also started due to concern for sepsis; ultimately, no infectious source was identified. The evening of hospital day 3, the patient passed substantial melenic stool with a concomitant 5 g/dL decrease in hemoglobin. Emergent esophagogastroduodenoscopy was performed (Figure).
FigureAcute esophageal necrosis. (A) Endoscopic view of the distal esophagus showing diffuse mucosal congestion, discoloration, erythema, and hemorrhagic changes consistent with acute esophageal necrosis. (B) Computed tomography angiography scan of the chest showing circumferential thickening of the esophagus.
This case shows a rare but important cause of upper gastrointestinal bleeding more commonly found in critically ill elderly patients termed acute esophageal necrosis (AEN). Endoscopy often reveals circumferential, black-appearing esophagus with predilection for the distal portion due to its comparatively poorer vascularization. The mechanisms of AEN, also known as “black esophagus,” include tissue hypoperfusion during low flow states, reflux of gastric contents, impaired mucosal barriers, and underlying chronic vascular disease.
Colón AR, Kamboj AK, Hagen CE, et al. Acute esophageal necrosis: a retrospective cohort study highlighting the Mayo Clinic experience [Epub ahead of print]. Mayo Clin Proc. 2022;S0025-6196(22)00195-1.
In our case, the underlying triggers included non–ST-elevation myocardial infarction, hypotension, and possibly sepsis. Management includes volume resuscitation and correction of the underlying process. Although AEN carries a poor prognosis with mortality reaching up to 36%, patients typically succumb to the underlying condition, with only 6% of deaths directly attributable to AEN.
Colón AR, Kamboj AK, Hagen CE, et al. Acute esophageal necrosis: a retrospective cohort study highlighting the Mayo Clinic experience [Epub ahead of print]. Mayo Clin Proc. 2022;S0025-6196(22)00195-1.
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