Acute esophageal necrosis occurring in a patient undergoing percutaneous coronary intervention

Diagnosis and management of acute esophageal necrosis

Acute esophageal necrosis is a rare syndrome classically characterized by a striking endoscopic image of diffuse and circumferential black mucosal discoloration of distal esophagus, with an abrupt transition at the gastroesophageal junction and variable proximal extension. The typical patient is an older male with general debilitation and multiple comorbidities presenting with hematemesis or melena. The pathophysiology usually involves a combination of esophageal ischemia, backflow injury from gastric chemical contents and impaired mucosal reparative mechanisms associated with debilitated physical states. It may arise in the setting of hemodynamic compromise, diabetic ketoacidosis, hypothermia, alcoholic intoxication, trauma, inflammatory diseases, esophageal local infection, solid organ transplantation, postoperative status, drugs or acute gastric outlet obstruction, usually in the background of a chronic debilitating process, where the concurrent presence of multiple risk factors, including diabetes mellitus, hypertension, malnutrition, malignancy or alcohol abuse, places a patient at higher risk. The characteristic endoscopic appearance establishes the diagnosis. Biopsy is supportive but not required. Management is mainly supportive and consists of correcting coexisting conditions, fluid therapy, bowel rest, intravenous proton pump inhibitor therapy and red blood cell transfusion as needed. Although this is a serious life-threatening condition, appropriate treatment may result in a favorable outcome in the majority of patients.

A case report: black oesophagus as a possible complication of transcatheter aortic valve implantation

Background

The increasing number of transcatheter aortic valve implantation (TAVI) in the last few years has unveiled a unique set of events and complications that need prompt recognition and management in order to improve patient outcomes, often involving a multidisciplinary team.

Case summary

We present a case of a 86-year-old woman with symptomatic severe aortic stenosis that underwent a TAVI and, in the post-procedure period, presented with acute abundant haematemesis, haemodynamic instability, and haemoglobin drop. The diagnosis of acute necrotizing oesophagitis (ANE) was made by upper gastrointestinal endoscopy.

Discussion

Acute necrotizing oesophagitis is a rare entity caused usually by an ischaemic insult in the presence of predisposing factors; it has a high rate of complications and mortality. To the best of our knowledge, this is the first clinical case report to describe the occurrence of ANE as a possible complication of TAVI and is also an example of the importance of the multidisciplinary approach of these complex patients, which extends even beyond the concept of Heart Team.

Clinical presentations, management, and outcomes of acute esophageal necrosis: a systemic review

BACKGROUND

To review all the reported literature on acute esophageal necrosis.

RESEARCH METHODS

Databases were searched using the special Medical Subject Heading (MeSH) terms. All the available reported cases of acute esophageal necrosis were analyzed.

RESULTS

A total of 154 cases were identified and 130 cases were analyzed. The mean age of presentation was 61 years, and 70% of cases were males. The most common presenting symptoms were hematemesis in 66%, shock in 36%, melena in 33%, abdominal or substernal pain in 28%. The most common comorbidities reported were diabetes in 38%, hypertension in 37%, alcohol abuse in 25%, and chronic kidney disease in 16%. On upper endoscopy, 51% had a distal disease, 36% had pan esophageal, and only 2% had a proximal disease. 84% of patients were treated with IV Proton Pump Inhibitors, 22% received transfusions, 23% got antibiotics for underlying sepsis, 14% also received sucralfate, and 4% required surgery for treatment. The mortality rate was 32%, while perforation was reported in 5% and stricture formation reported in 9% of patients.

CONCLUSIONS

Patients with acute esophageal necrosis can have a favorable outcome if treated appropriately.

Comprehensive review of acute oesophageal necrosis

Acute oesophageal necrosis, also known as 'black oesophagus', is a rare condition characterised by the black discolouration of the oesophageal mucosa on endoscopy and involves the distal oesophagus in majority of cases but may also extend proximally. A number of conditions are found to be associated with it and it is thought to occur due to a combination of hypovolaemia and inadequate oesophageal protective mucosal barrier function. Gastric secretions may have a direct effect on the oesophageal mucosa. We present a case of a woman who presented with haematemesis and significant hypotension after a session of haemodialysis. Black oesophagus was confirmed on esophagogastroduodenoscopy. She was given two units of packed red blood cells and one unit of platelets, and started on a pantoprazole infusion. However, despite rigorous attempts at resuscitation the patient failed to recover.