1819 The Black Esophagus in the Renal Transplant Patient

• Published in: The American journal of gastroenterology Vol. 114; no. 1; p. S1021
• Main Authors: Yu, Michael, Mulki, Ramzi, Massaad, Julia
• Format: Journal Article
• Language: English
• Published: 01.10.2019
• ISSN: 0002-9270; 1572-0241
• DOI: 10.14309/01.ajg.0000596808.65741.7e

INTRODUCTION: Acute esophageal necrosis (AEN) is an uncommon disease characterized by gastrointestinal bleeding and endoscopic findings of circumferential black-colored necrosis of the distal esophagus. Patients at risk include elderly males over the age of 65, who typically have multiple chronic medical issues including vascular disease and diabetes. Mortality is reported to be 32%. Here, we present a case of AEN in a renal transplant patient and describe potential inciting factors such as immunosuppression and opportunistic diseases. CASE DESCRIPTION/METHODS: A 35-year-old male with ESRD from hypertensive nephrosclerosis s/p kidney transplant presented with worsening chronic right foot pain. He was found to have right lower extremity limb ischemia was started on heparin. On hospital day 3, he underwent successful revascularization of his R lower extremity. Post-procedural WBC and Hb were 20,000/mL and 12.5 g/dL, respectively. On postoperative day (POD) 3, WBC worsened to 25,400/mL and Hb decreased to 9.6 g/dL. On POD4, he had 3 episodes of melena and his HB dropped to 7.3 g/dL. EGD showed LA Grade D esophagitis in the mid and distal esophagus with necrotic appearing mucosa in the distal esophagus. A CT chest/abdomen with oral contrast performed after the EGD showed circumferential thickening of the distal esophagus. Patient was treated with sucralfate and pantoprazole. He was bridged to warfarin and discharged. On follow up, his Hb improved to 10.9 g/dL. DISCUSSION: Our patient was admitted for limb ischemia likely aggravated by peripheral vascular disease of renal disease. He underwent revascularization of his right lower limb which added a component of hemodynamic compromise. As a renal transplant patient, he has multiple comorbidities placing at risk for developing AEN. First, kidney disease gives a higher chance of developing vascular disease. Next, as a transplant patient, he was receiving various immunosuppressing agents like corticosteroids and MMF which also reduce the protective function of the gastrointestinal mucosa. Other risk factors include opportunistic infections and transplant rejection. Caution is needed when caring for renal transplant patients, and following major procedures with significant hemodynamic insult, an EGD should be considered.