(189) Black Warning: Acute Esophageal Necrosis Resulting From Type B Aortic Dissection

Introduction: Acute esophageal necrosis, or “black esophagus” due to its characteristic appearance on EGD, is caused by a hypoperfusion event of the esophagus and a local insult leading to increased metabolic demand. Diffuse esophageal necrosis is an extremely rare and deadly complication, but can be seen in the case of type B aortic dissection. We present a case of diffuse esophageal necrosis with perforation as a direct result of type B aortic dissection and intramural hematoma.

Description: A 56-year-old male presented with abdominal pain, nausea, and vomiting was admitted for concern for pancreatic pseudocyst and was incidentally found to have type B aortic dissection and intramural aortic hematoma. Vascular surgery was consulted and the patient was admitted to ICU for further management and started on impulse control. Throughout admission, pulses remained intact along with neurologic status and renal function. On HD#4, the patient developed worsening abdominal and back pain with an acute decline in respiratory status. Stat imaging was obtained and demonstrated pseudomediastinum with concern for esophageal perforation. Following successful intubation and resuscitation, EGD was performed and confirmed severe esophageal necrosis throughout the entire esophagus with a large perforation in the distal esophagus to gastroesophageal junction. CT esophagram was recommended to further characterize the esophageal necrosis, however given complicated clinical course and multiple comorbidities, patient ultimately expired with hospice services.

Discussion: Acute esophageal necrosis is an extremely rare and almost always lethal complication of type B aortic aneurysm and dissection. Esophageal necrosis that is diffuse with mid esophageal involvement is rarely described as it typically only involves the distal esophagus, but can be seen in the setting of type B aortic aneurysm and dissection. This relates to the lack of arterial perfusion if the blood supply is provided by the false lumen of the dissection, or following hematoma formation secondary to compression of venous outflow. Ultimately, despite adequate perfusion of other organs and limbs in type B aortic dissection, given its high mortality rate, there should be a low suspicion for early evaluation of esophageal necrosis to expedite prompt treatment.