A Case of Acute Esophageal Necrosis and Duodenal Disease in a Patient With Adrenal Insufficiency

Abstract

A 62-year-old man presented to the emergency department for 2 days of generalized weakness and symptomatic hypotension. His past medical history was significant for idiopathic end-stage renal disease, primary adrenal insufficiency on daily prednisone, and pressure ulcers on his posterior thighs. On presentation, his blood pressure was 76/46 mm Hg, heart rate 97 beats per minute, and temperature 36.8 C. He had erythematous posterior thigh ulcers. His white blood cell count was 18 Â 10 9 cells/L and hemoglobin 12.8 g/dL. He was treated for sepsis from infection of his lower extremity ulcers. He had a prolonged hospital course complicated by deep venous thrombosis requiring warfarin therapy and persistent hypotension from primary adrenal insufficiency and sepsis. On hospital day 17, the patient suddenly experienced severe hematemesis and cardiac arrest with asystole. His international normalized ratio was 10 and hemoglobin was 3.9 g/dL. The patient was resuscitated. Upper endoscopy was performed for gastrointestinal bleeding and revealed black circumferential necrosis in the lower two-thirds of the esophagus consistent with acute esophageal necrosis (AEN) (Figure A). The stomach was normal in appearance, and the duodenum was pale, ulcerated, and ischemic appearing (Figure B). There was no active bleeding, and no further interventions were performed. The patient had no meaningful neurologic recovery and died several days later.

Diagnosis and management of acute esophageal necrosis

“…Other causes of hemodynamic compromise resulting in AEN include excessive doses of antihypertensive drugs, especially with a combination of different classes [36], hypovolemic shock secondary to diarrhea and vomiting [37,38], or adrenal insufficiency [39]. AEN may also develop following trauma caused by falls or vehicle accidents.…”

“…This characteristic endoscopic appearance is sufficient to establish the diagnosis. Additional endoscopic findings may include signs of bleeding (active oozing from distal esophagus [106], blood clots [26] and/or “coffee ground” material in the stomach [85], multiple esophageal ulcerations [106], gastric ulcers [37], duodenal pathology (ulcers, erosions or edema) [39], or gastric outlet obstruction due to gastric volvulus [19].…”

Comprehensive review of acute oesophageal necrosis

“…Of these cases, we managed to extract data from 79 articles having 105 cases of AON (online supplementary table 1). 5–82 Data could not be extracted from (n=13) of the articles containing a total of (n=20) cases 4 83–95. The most common reasons for these were unavailability of complete data or the language being other than English.…”

Black esophagus as an autopsy discovery: a challenging interpretation

“…Case reports published in literature reviews were also included on the condition that patient history was sufficiently detailed. The endoscopy series initially included 88 publications, of which 26 publications on a total of 41 deceased patients were retained (Gurvits et al 2015;Ben Soussan et al 2002;Averbukh et al 2018;Barnes et al 2014;Day and Sayegh 2010;Del Hierro 2011;Essamri et al 2001;Grudell et al 2006;Julian Gomez et al 2008;Kalva et al 2016;Katsinelos et al 2004;Koop et al 2016;Lahbabi et al 2013;Maher and Nassar 2008;Odelowo et al 2002;Ramos et al 2008;Rodrigues et al 2016;Roman Fernandez et al 2014;Salem et al 2015;Shafa et al 2016;Shah et al 2017;Sharma et al 2016;Singh et al 2011;Wu and Wu 2014;Monteiro et al 2019;Khan et al 2019). The autopsy series initially comprised 13 publications, of which 11 publications on a total of 17 patients were retained in this review.…”