P4029 - Acute Esophageal Necrosis: A Rare Case With an Unusual Challenge

Minni Meka, MD¹, Sagar V. Mehta, MD², Lissette Pola, DO^1
1Nova Southeastern University, Wellington, FL; ²Wellington Regional Medical Center, Wellington, FL

Introduction: Acute esophageal necrosis (AEN), also known as Gurvits syndrome, is a rare clinical condition, with uncertain etiology. Rare in itself, this case report also highlights navigation of a unique clinical situation requiring trans-esophageal echocardiography (TEE) for Methicillin resistant Staphylococcus Aureus (MRSA) bacteremia.

Case Description/Methods: Patient is a 69-year-old male presenting with 1 day history of upper abdominal pain, nausea, coffee-ground emesis. Prior medical history includes Type 2 diabetes mellitus, coronary artery disease, status post permanent pace maker insertion, chronic low back pain. Patient reported taking NSAIDs, Percocet and aspirin. On admission we noted a hemoglobin of 9.5 g/dl, a drop from previous hemoglobin of 11.6 g/dl 1 month ago, as well as an increase in Blood urea nitrogen (BUN) from 27 to 56. Esophagogastroduodenoscopy (EGD) revealed severe esophagitis, blackened necrotic appearing mucosa. Histology was consistent with tissue necrosis. A diagnosis of AEN was made. The patient received nothing by mouth and an intravenous (IV) proton pump inhibitor (PPI). Patient’s clinical course took an interesting turn when blood cultures were positive for MRSA with an indication for TEE. Patient was deemed to be at high risk of esophageal complications and was transferred to a higher center for alternative cardiac imaging and pacemaker removal. Upon clinical improvement EGD performed 4 weeks later showed significant resolution of necrosis but with some residual esophagitis.

Discussion: AEN is a rare clinical entity arising in the setting of multiorgan dysfunction, ischemia, sepsis, diabetic ketoacidosis, trauma, toxic ingestion and/or volume depletion that leads to ischemia and necrosis. Notable symptoms are upper gastrointestinal bleeding, melena, nausea, vomiting, dysphagia, abdominal pain. Diagnosis is made by EGD showing black circumferential esophagus in part or total extension to the gastroesophageal junction. Treatment includes systemic resuscitation with IV fluid therapy, glycemic control, use of IV PPI and parenteral nutrition. A mortality rate as high as 32% has been reported, likely related to comorbidities, acute complications such as perforation and mediastinitis. AEN should therefore be on the list of differential diagnoses for any upper GI bleeding. Also, in situations where a TEE is indicated as in this case, clinicians should be vigilant in avoiding the procedure and seeking alternative cardiac imaging modalities due to higher risk of complications.







Disclosures:


Minni Meka, MD¹, Sagar V. Mehta, MD², Lissette Pola, DO¹. P4029 - Acute Esophageal Necrosis: A Rare Case With an Unusual Challenge, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.