Portal de Periódicos da CAPES

Beware of the Darkness

2013; Lippincott Williams & Wilkins; Volume: 108; Linguagem: Inglês

10.14309/00000434-201310001-00004

1572-0241

Umesha Naragalu Boregowda, Andrew Batey, Manav Sharma, Nupur Gupta,

Purpose: “Acute esophageal necrosis,” also known as black esophagus is distinctive endoscopic appearance of esophagus. Methods: A 60-year-old man with history of chronic diabetes and alcohol abuse presented to emergency room with 3 month history of watery diarrhea, intermittent nausea, vomiting and 20-lb weight loss. He denied hematochezia, hematemesis, recent travel, sick contact, or recent antibiotic use. Review of systems was positive for difficulty swallowing, anorexia, abdominal pain, and fatigue. He had a previous Whipple's procedure due to pancreatic pseudocyst secondary to alcoholic pancreatitis. Examination revealed a frail, malnourished male with stable vital signs and conjunctival pallor. Cardiac, respiratory, abdominal and neurological examinations were unremarkable. Laboratory exam revealed hemoglobin 7.4 gm/l, WBC 9.7k/dl, INR 2.4. Stool studies for Clostridium difficile toxin and enteric pathogens were negative. Patient was started on IV fluids and transfused two units of packed cells. An upper endoscopy done following an episode of hematemesis revealed circumferential “blackened distal esophageal mucosa” with clear demarcation at the gastro-esophageal junction and ischemic changes in the duodenal mucosa, characterized by linear ulcers and scattered eschar formation. Subsequently, he had a massive upper GI hemorrhage- unresponsive to blood transfusion and fluid resuscitation. Patient died of hypovolemic shock and multi organ failure. Esophageal biopsies revealed acute inflammatory exudates, blood clot and fibrin, with no viable tissue. Results: Acute esophageal necrosis also known as “black esophagus” is an uncommon endoscopic finding described as diffuse black discoloration of the distal esophagus with clear demarcation at the gastroesophageal junction. Incidence is 0.01% to 0.2 % of upper GI endoscopies. Mortality ranges from 33-50%. It is attributed, in part, to hypoperfusion and direct acidic injury due to massive reflux of gastric content. Risk factors include alcohol abuse, advanced age, male gender, malignancies, gastric outlet obstruction, hypercoagulable state, and diabetes. Patients may present with nausea, vomiting, heart burn, hematemesis, and melena. It should be differentiated from caustic injury, acanthosis nigricans, pseudomelanosis, and coal dust deposition. Treatment includes nasogastric tube insertion, blood transfusions, IV proton pump inhibitors and total parenteral nutrition until recovery, which can take 3-6 weeks. Usual complications include perforation, mediastinitis, stricture formation, and secondary infection. Conclusion: Black esophagus is an indication of diffuse esophageal necrosis and high mortality, and should be monitored in critical care setting.