Black Esophagus – a Rare Cause of Gastrointestinal Bleeding: 786

Purpose: 66 yr male with a medical history of ESRD, DM, and PVD requiring femoral-popliteal bypass surgery was admitted with bilateral lower extremity claudication. The diagnostic work-up revealed failure of the bypass grafts; the patient subsequently required bilateral above the knee amputations. His operative course was remarkable for sustained periods of hypotension. On post-op day 3, the patient had multiple episodes of melena with an acute drop in hemoglobin of 2 g without abdominal pain. An upper endoscopy was performed. Esophageal necrosis was present circumferentially immediately below the circopharyngeus and extended to the GEJ (photographs 1 and 2). The remainder of the endoscopy was normal; acute esophageal necrosis was presumed to be the etiology of the bleed. Biopsies revealed necrotic debris with acute inflammatory leukocytic infiltration. The patient was treated conservatively with high dose proton-pump inhibitor therapy and maximization of cardiac output. He recovered without complication. Acute esophageal necrosis, or black esophagus, is a rare endoscopic finding, with only a handful of cases described in the world literature. The incidence has been reported to be 0.0125% to 0.2%, with a predominance of the cases involving men mean age 65. The proposed pathophysiology involves ischemia in a majority of cases; massive gastroesophageal reflux, infection, and caustic ingestion have also been implicated. Associated risk factors have included atherosclerotic vascular disease, diabetes, end stage renal disease, and recent surgery – all of which were common to the patient presented. Treatment is largely supportive with bowel rest, high dose PPI therapy, and optimization of cardiac perfusion. Despite supportive care, mortality rates approach 32%.FigureFigure