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Critical Care |

Acute Esophageal Necrosis in Severe Sepsis

Arnoldo Cavazos*, MD; Remigio Puente-Carrillo, MD; José Felipe Villegas-Elizondo, MD; Roberto Mercado-Longoria, MD; Juan Israel Escobedo-Bernal, MD; Michelle Acosta-Moreno, MD; Cesar Preciado-Yepez, MD
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Universidad Autónoma de Nuevo León, Monterrey, Mexico


Chest. 2012;142(4_MeetingAbstracts):332A. doi:10.1378/chest.1388180
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Abstract

SESSION TYPE: Critical Care Student/Resident Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute esophageal necrosis (AEN) is a rare condition described as a circumferential dark lesion in the distal third of esophagus (1,2,3). We present the case of a patient with AEN and severe sepsis.

CASE PRESENTATION: A 49 - year - old male was admitted due to acute rectal bleeding. He is a chronic consumer of heavy amounts of alcohol and has smoked 50 packs - year. He also has a long history of diabetes mellitus, systemic arterial hypertension and underwent a coronary artery bypass surgery eight years before actual admission. Acute rectal bleeding was secondary to accidental introduction of foreign body through anus. At the Emergency Room, we found tachycardia, tachypnea and left lower quadrant abdominal pain with no peristalsis. The digital rectal examination was positive for fresh blood. His paraclinical tests reported leukocytosis and lactic acidosis. An abdominal computed tomography was obtained and showed free air and extra - intestinal leakage of contrast agent in pelvic cavity. Patient underwent an exploratory laparotomy. Two centimeters of diameter rectal perforation was found and repaired. He was admitted to Intensive Care Unit (ICU) with positive criteria for severe sepsis and acute respiratory distress syndrome. His APACHE II score was 16 points. A Swan - Ganz catheter was placed and showed a septic hemodynamic profile. Early goal directed therapy for sepsis was implemented. The patient presented upper gastrointestinal bleeding and hemodynamic instability on the third day in ICU. Endoscopy revealed necrotic esophagitis in the distal part of esophagus. In spite of treatment with cristaloids, packed red blood cells, vasoactive drugs and proton pump inhibitors, the patient subsequently died.

DISCUSSION: Ischemia is the etiological mechanism most frequently related to AEN (3), but the condition has been associated with impaired mucosal defense system, multiple organ dysfunction, hypoperfusion states, vascular disease, sepsis and diabetic ketoacidosis (1). Upper gastrointestinal hemorrhage is a typical presentation (1,2,3). Treatment consists of maintaining hemodynamic stability, bowel rest, and proton pump inhibitors. Mortality reported in literature is 32% (1,2,3)

CONCLUSIONS: AEN is a rare condition associated with many clinical situations. Treatment is mainly supportive and mortality is high.

1) Gurvits GE. Black esophagus: acute esophageal necrosis syndrome. World J Gastroenterol 2010; Jul 14;16(26):3219-25

2) Gurvits GE, Shapsis A, Lau N et al. Acute esophageal necrosis: a rare syndrome. J Gastroenterol. 2007; Jan;42(1):29-38.

3) Dushyant Singh, Reetu Singh , Alexandra S. Laya. Acute esophageal necrosis: a case series of five patients presenting with “Black esophagus”. Indian J Gastroenterol 2011; Jan 2011; 30(1):41 - 45

DISCLOSURE: The following authors have nothing to disclose: Arnoldo Cavazos, Remigio Puente-Carrillo, José Felipe Villegas - Elizondo, Roberto Mercado - Longoria, Juan Israel Escobedo - Bernal, Michelle Acosta - Moreno, Cesar Preciado-Yepez

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Universidad Autónoma de Nuevo León, Monterrey, Mexico

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