A relapse case of acute necrotizing esophagitis

Table of Contents

Acute necrotizing esophagitis (ANE) is a severe form of acute esophagitis that appears dark black in color (”black esophagus”) at endoscopy due to mucosal necrosis [1]. ANE is an uncommon condition of unknown etiology. Grudell et al. reported that among 52 cases of ANE, seven cases involved massive gastroesophageal reflux [2]. As gastroesophageal reflux is one of the proposed causes of ANE [3] [4], treatment generally includes administration of a proton pump inhibitor (PPI).

A 67-year-old man complained of vomiting and chest pain 5 days after surgery for a vitreous hemorrhage. The patient had a history of diabetes mellitus, hypertension, hyperlipidaemia, and angina pectoris. Endoscopy revealed a black-appearing esophageal mucosa extending from the proximal two thirds of the esophagus to the cardia ([Fig. 1]). After 6 days of treatment that included oral nutritional rest for 1 week and rabeplazole (20 mg/day), the mucosal surface was diffusely covered with whitish exudates ([Fig. 2]), and biopsy specimens consisted of necrotic debris. By continuing to take rabeplazole for 4 months after release from hospital, the patient was cured of esophagitis ([Fig. 3]). However, 37 days after finishing the rabeplazole treatment, the patient returned due to recurring vomiting and chest pain. Endoscopy revealed a reoccurrence of the black-appearing esophageal mucosa and whitish exudates, as well as mucosal bleeding ([Fig. 4]). Upon reestablishment of the treatment described previously, the relapsed ANE improved considerably within 3 weeks. With continued administration of rabeplazole, the ANE has not relapsed.

Fig. 1 Endoscopy revealed a black-appearing esophageal mucosa extending from the proximal two thirds of the esophagus to the cardia.

Fig. 2 After 6 days of treatment, the esophageal surface was diffusely covered with whitish exudates.

Fig. 3 By continuing to take rabeplazole for 4 months after release from hospital, the patient was cured of esophagitis.

Fig. 4 The patient returned 37 days after finishing the rabeplazole treatment, and endoscopy revealed a reoccurrence of the black-appearing esophageal mucosa and whitish exudates, as well as mucosal bleeding.

To our knowledge, this is the first reported case of a relapse of ANE [2] [5]. In this case, relapse may have been associated with acid backflow, and we hypothesize that if the patient were to discontinue the PPI, he would experience another relapse.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AD

References

• 1 Goldenberg S P, Wain S L, Marignani P. Acute necrotizing esophagitis.  Gastroenterology. 1990;  98 493-496
• 2 Grudell A B, Mueller P S, Viggiano T R. Black esophagus: report of six cases and review of the literature, 1963 - 2003.  Dis Esophagus. 2006;  19 105-110
• 3 Katsinelos P, Pilpilidis I, Dimiropoulos S. et al . Black esophagus induced by severe vomiting in a healthy young man.  Surg Endosc. 2003;  17 521
• 4 Reichart M, Busch O R, Bruno M J. et al . Black esophagus: a view in the dark.  Dis Esophagus. 2000;  13 311-313
• 5 Augusto F, Fernandes V, Cremers M I. et al . Acute necrotizing esophagitis: a large retrospective case series.  Endoscopy. 2004;  36 411-415