270 Acute esophageal necrosis in a 15-year old boy – a case report

• Published in: Archives of disease in childhood Vol. 106; no. Suppl 2; p. A114
• Main Authors: Omerza, Lana, Tješić-Drinković, Duška, Senečić-Čala, Irena, Aničić, Mirna Natalija, Stančić-Rokotov, Dinko, Vuković, Jurica
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health 11.10.2021; BMJ Publishing Group LTD
• Subjects: Abstracts; Antibiotics; Attrition (Research Studies); Bleeding; Case reports; Diabetes mellitus; Endoscopy; Erythrocytes; Esophagus; Hemoglobin; Hemorrhage; Ischemia; Malignancy; Mechanical ventilation; Mediastinitis; Microvasculature; Mortality; Mucosa; Necrosis; Ostomy; Parenteral nutrition; Patients; Pediatrics; Risk factors; Scoliosis; Stenosis; Stricture; Surgery; Thorax; Thrombosis; Ventilation
• ISSN: 0003-9888; 1468-2044
• DOI: 10.1136/archdischild-2021-europaediatrics.270

Acute esophageal necrosis (black esophagus, Gurvits syndrome) is a rare clinical entity which leads to upper gastrointestinal bleeding. First description dates to 1990, with around115 cases described in the literature. The condition has pathognomonic endoscopic appearance characterized by circumferential black mucosa in the distal esophagus, and discontinuing abruptly at the gastroesophageal junction. The pathogenesis is unclear, apparently multifactorial mucosal ischemia due to low flow vascular state or microvascular thrombosis is predisposing to topical damage by gastric content reflux. It’s commonly seen in elderly men, with risk factors like diabetes, malignancy, alcohol consumption, shock, major surgery.Diagnosis is made endoscopically.Management requires hemodynamic stabilization, acid suppressive medication with avoidance of nasogastric tube placement. The condition has very poor prognosis, with mortality rate up to 35%, and various complications including strictures and stenosis, perforation with mediastinitis and abscess formation.Our patient, a 15 year old boy underwent surgery for scoliosis. During the immediate post surgical period he had hematemesis with consequent hemorrhagic shock. He was stabilized (IV fluids, packed red blood cells), nasogastric tube was inserted with evacuation of around 160 mL of blood and he was referred to our ICU. He required mechanical respiratory support and inotropic medications. Continuous parenteral PPI therapy was commenced.Black, charcoal-like content was draining from the nasogastric tube, with further deterioration in hemoglobin levels.Esophagogastroduodenoscopy showed black mucosa of lower esophagus, partly circumferential, partly linear, with cutoff at gastroesophageal junction.There were no radiological signs of esophageal perforation, bilateral lung consolidates were surrounded by ground-glass interstitial changes.Patient was kept NPO, on parenteral nutrition, with PPI and antibiotic treatment. He was weaned mechanical ventilation after three days, followed by brief stint of non-invasive respiratory support.Unfortunately, significant stenosis with stricture formed in the area overlying initial necrosis. After several attempts of endoscopic ballon dilatation, refractory strictures reemerged. Surgical gastrostomy was performed to enable sufficient enteral caloric intake, and bring the patient to ideal physical condition for further treatment.Planned colonic interposition surgery was not performed because of inadequate length of colon, hence thoracic surgeons performed retrosternal esophagogastroplasty Our patient had no further postoperative complications and was able to establish adequate oral feeding.Acute esophageal necrosis should be considered as one of the causes of upper gastrointestinal bleeding, especially because its high mortality and complications rate requires immediate and aggressive early management.