Acute Esophageal Necrosis: Rare Cause of Upper Gastrointestinal Bleeding

Introduction: Acute esophageal necrosis is rare cause of upper gastrointestinal bleeding. The incidence of acute esophageal necrosis is four times higher in men than women with a mean age of 68 years at diagnosis. Case Description/Methods: We are presenting a 68-year-old male who was admitted with DKA. He later developed melena. His initial laboratory showed; Hgb 12.2 gm/dl and Hct 39%. However, his Hgb drooped to 6.8gm/dl. Gastroenterology did upper endoscopy which showed circumferential black discoloration from gastroesophageal junction (GEJ) at 38 cm to 20 cm proximally. Mucosa was friable. There is abrupt transition to normal gastric mucosa beyond GEJ. Otherwise, stomach and duodenum appear normal. Biopsy showed severe esophagitis with ulceration and necrosis. Patient was managed conservatively with intravenous pantoprazole, hydration, and nothing by mouth for few days. Patient continued to improve without recurrence of GI bleed, maintained hemoglobin and tolerated diet. Discussion: Acute esophageal necrosis has been associated with broad spectrum antibiotic use, infections like Candida albicans, and DKA. Our patient primary presentation is due to DKA and pathology revealed superimposed candida infection. Approximately 70 percent of patients with acute esophageal necrosis present with upper gastrointestinal bleeding with hematemesis and melena. Endoscopy is the main diagnostic modality. It is characterized by circumferential black discoloration with underlying friable hemorrhagic tissue and by a sharp transition to normal-appearing mucosa at the gastroesophageal junction. Initial management consists intravenous fluids and treatment of the underlying illness and gastric acid suppression with intravenous proton pump inhibitors. Oral intake should be avoided for at least 24 hours.Figure 1.: Circumferential black discoloration.