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http://jsms.sch.ac.kr 115 Acute Esophageal Necrosis Associated with Esophageal Foreign Body Injury and the Development of Pneumomediastinum Mi Na Kim 1 , Yong Kang Lee 1 , A Ra Choi 1 , Yoon Hea Park 1 , Dowhan Kim 2 , Yong Chan Lee 1,3 , Hyuk Lee 1,3 Departments of 1 Internal Medicine and 2 Pathology, 3 Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea A 74-year-old woman complained of dysphagia and hemoptysis after ingesting a fragment of crab shell while eating crab salted- fermented fish products, and presented dyspnea that had lasted for three days. Computed tomography indicated pneumomedias- tinum. Laboratory results revealed acute renal failure. The patient experienced respiratory distress and shock over the days follow- ing her initial presentation. Upper gastrointestinal endoscopy revealed black pigmentation of the esophageal mucosa from the mid- dle to lower esophagus. Despite intensive care, the patient’s condition deteriorated and she died. This is the first case of acute eso- phageal necrosis associated with esophageal foreign body injury and the development of pneumomediastinum reported in Korea. Keywords: Acute esophageal necrosis; Foreign body injury; Endoscopy; Pneumomediastinum INTRODUCTION Acute esophageal necrosis (AEN) is a rare condition character- ized by endoscopic findings of dark esophageal discoloration that abruptly stops at the gastroesophageal junction [1-3]. e reported incidence of AEN is very low, ranging from 0.0125 to 0.2% [4,5]. e precise etiology of AEN is unknown, but the condition appears most oſten to arise from ischemia, viral infection, trauma, or cor- rosive injury [4,6,7]. e most common clinical presentation is up- per gastrointestinal bleeding [8,9]. e prognosis of AEN is vari- able, and depends on the underlying illness [1]. We describe a case of AEN associated with pneumomediastinum that was caused by esophageal injury. CASE REPORT A 74-year-old woman complained of dysphagia and hemoptysis aſter ingesting a fragment of crab shell while eating crab salted- fermented fish products and presented to our department with dyspnea that had lasted for three days. e patient had a history of diabetes mellitus and hypertension. Upon admission to our hospi- tal, she was afebrile, with a regular pulse of 99 bpm, a blood pres- sure of 160/70 mmHg, and a respiratory rate of 20 breaths/min. She suffered from dyspnea, but O2 saturation was sustained over 95% with 4 L of O2 administered by nasal cannula. The digital rectal examination was negative for blood. A test irrigation with normal saline via a nasogastric tube was also negative for blood. Non contrast-enhanced computed tomography revealed extensive pneumomediastinum but no definite esophageal injury site (Fig. 1). e patient’ s laboratory values included white blood cell count 6,560/µL (neutrophils 84.1%), hemoglobin 13.4 g/dL, platelets 219,000/µL, blood urea nitrogen 106.5 mg/dL, creatinine 8.97 mg/ dL, total bilirubin 6.1 mg/dL, sodium 124 mmol/L, and potassium 4.1 mmol/L. Laboratory investigation revealed acute renal failure. e patient was transferred to the intensive care unit and started continuous renal replacement therapy. On day 3, the patient suf- fered severe dyspnea and desaturated and was connected to me- chanical ventilation. Endoscopy revealed black pigmentation of the esophageal mucosa with a friable hemorrhagic area covered with yellowish exudate from the mid to distal esophagus. ere was no evidence of perforation throughout esophagus (Fig. 2A). e black pigmentation of the mucosa ended sharply at the gastro- Soonchunhyang Medical Science 17(2):115-117, December 2011 pISSN: 2233-4289 I eISSN: 2233-4297 CASE REPORT Correspondence to: Hyuk Lee Department of Internal Medicine, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul 120-752, Korea Tel: +82-2-2228-1978, Fax: +82-2-393-6884, E-mail: [email protected] Received: Sep. 6, 2011 / Accepted after revision: Dec. 12, 2011 © 2011 Soonchunhyang Medical Research Institute This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/).
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Acute Esophageal Necrosis Associated with Esophageal Foreign Body Injury and the Development of PneumomediastinumMi Na Kim1, Yong Kang Lee1, A Ra Choi1, Yoon Hea Park1, Dowhan Kim2, Yong Chan Lee1,3, Hyuk Lee1,3
Departments of 1Internal Medicine and 2Pathology, 3Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
A 74-year-old woman complained of dysphagia and hemoptysis after ingesting a fragment of crab shell while eating crab salted-fermented fish products, and presented dyspnea that had lasted for three days. Computed tomography indicated pneumomedias-tinum. Laboratory results revealed acute renal failure. The patient experienced respiratory distress and shock over the days follow-ing her initial presentation. Upper gastrointestinal endoscopy revealed black pigmentation of the esophageal mucosa from the mid-dle to lower esophagus. Despite intensive care, the patient’s condition deteriorated and she died. This is the first case of acute eso-phageal necrosis associated with esophageal foreign body injury and the development of pneumomediastinum reported in Korea.
Keywords: Acute esophageal necrosis; Foreign body injury; Endoscopy; Pneumomediastinum
INTRODUCTION
Acuteesophagealnecrosis(AEN)isarareconditioncharacter-izedbyendoscopicfindingsofdarkesophagealdiscolorationthatabruptlystopsatthegastroesophagealjunction[1-3].ThereportedincidenceofAENisverylow,rangingfrom0.0125to0.2%[4,5].ThepreciseetiologyofAENisunknown,buttheconditionappearsmostoftentoarisefromischemia,viralinfection,trauma,orcor-rosiveinjury[4,6,7].Themostcommonclinicalpresentationisup-pergastrointestinalbleeding[8,9].TheprognosisofAENisvari-able,anddependsontheunderlyingillness[1].WedescribeacaseofAENassociatedwithpneumomediastinumthatwascausedbyesophagealinjury.
CASE REPORT
A74-year-oldwomancomplainedofdysphagiaandhemoptysisafteringestingafragmentofcrabshellwhileeatingcrabsalted-fermentedfishproductsandpresentedtoourdepartmentwithdyspneathathadlastedforthreedays.Thepatienthadahistoryofdiabetesmellitusandhypertension.Uponadmissiontoourhospi-
tal,shewasafebrile,witharegularpulseof99bpm,abloodpres-sureof160/70mmHg,andarespiratoryrateof20breaths/min.Shesufferedfromdyspnea,butO2saturationwassustainedover95%with4LofO2administeredbynasalcannula.Thedigitalrectalexaminationwasnegativeforblood.Atestirrigationwithnormalsalineviaanasogastrictubewasalsonegativeforblood.Noncontrast-enhancedcomputedtomographyrevealedextensivepneumomediastinumbutnodefiniteesophagealinjurysite(Fig.1).Thepatient’slaboratoryvaluesincludedwhitebloodcellcount6,560/µL(neutrophils84.1%),hemoglobin13.4g/dL,platelets219,000/µL,bloodureanitrogen106.5mg/dL,creatinine8.97mg/dL,totalbilirubin6.1mg/dL,sodium124mmol/L,andpotassium4.1mmol/L.Laboratoryinvestigationrevealedacuterenalfailure.Thepatientwastransferredtotheintensivecareunitandstartedcontinuousrenalreplacementtherapy.Onday3,thepatientsuf-feredseveredyspneaanddesaturatedandwasconnectedtome-chanicalventilation.Endoscopyrevealedblackpigmentationoftheesophagealmucosawithafriablehemorrhagicareacoveredwithyellowishexudatefromthemidtodistalesophagus.Therewasnoevidenceofperforationthroughoutesophagus(Fig.2A).Theblackpigmentationofthemucosaendedsharplyatthegastro-
Soonchunhyang Medical Science 17(2):115-117, December 2011 pISSN: 2233-4289 I eISSN: 2233-4297
CASE REPORT
Correspondence to: Hyuk LeeDepartment of Internal Medicine, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul 120-752, KoreaTel: +82-2-2228-1978, Fax: +82-2-393-6884, E-mail: [email protected]: Sep. 6, 2011 / Accepted after revision: Dec. 12, 2011
© 2011 Soonchunhyang Medical Research InstituteThis is an Open Access article distributed under the terms of the
Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/).
Kim MN, et al. • Acute Esophageal Necrosis Associated with Foreign Body Injury
Soonchunhyang Medical Science 17(2):115-117116 http://jsms.sch.ac.kr
Fig. 1. Computed tomography (CT) image of the patient. Extensive pneumome-diastinum was noted.
Fig. 3. Microscopic findings. Biopsied mucosa from the distal esophagus shows necrotic tissue and necroinflammatory exudate (H&E, × 200).
Fig. 2. Endoscopic findings of the esophagus. (A) Black pigmentation of the mucosa was noted from the middle to the lower esophagus. (B) Black pigmentation of the mucosa ended sharply at the gastroesophageal junction.
A B
esophagealjunction(Fig.2B).Anesophagealbiopsyindicatedanulcerandnecroinflammatoryexudate(Fig.3).Periodicacid-Schiffstainingrevealednoidentifiablefungalhyphae.Immunohisto-chemicalstainingforcytomegaloviruswasnegative.
Despiteintensivecare,thepatientremainedhemodynamicallyunstableandrequiredtheadministrationofvasoactiveagents.Herconditiondeterioratedoverthefollowingdays.Shewentintomul-tisystemorganfailureanddiedfromsepticshock.
DISCUSSION
AEN,alsoknownasblackesophagus,isararecondition[1-3].ItwasfirstdescribedbyGoldenbergetal.[10]in1990.Thereported
incidenceofAENisverylow,rangingfrom0.01to0.2%[5].ThemostcommonclinicalmanifestationofAENisuppergastrointes-tinalbleeding,butothercommonsymptomsareepigastricpainorburning,dysphagia,andvomiting[4,5,11].Malignantmelanoma,acanthosisnigricans,pseudomelanosis,melanosis,coaldustde-position,andcorrosiveingestionareconditionsthatshouldalsobeconsideredindifferentialdiagnosis[9,12].
ThepathogenesisofAENappearstobemultifactorial,andisch-emiaisthemostlikelycause[11].Themostfrequentinvolvedloca-tionofAENisthedistalthirdoftheesophagus,whichislessvas-cularizedthantheproximalandmiddleesophagus[6,9,13].AENisassociatedwithmultiplemedicalconditionsincludingrenalin-sufficiency,diabetesmellitus,cardiovasculardisease,hemodyna-
Acute Esophageal Necrosis Associated with Foreign Body Injury • Kim MN et al.
Soonchunhyang Medical Science 17(2):115-117 http://jsms.sch.ac.kr 117
miccompromise,hypoxemia,gastricoutletobstruction,alcoholingestion,malnutrition,andtrauma[6,8,14,15].
Inourcase,esophagealforeignbodyinjurycausingpneumo-mediastinumseemstohaveplayedanimportantroleinselectiveesophagealischemia.Mostsuchforeignbodieswillpassspontane-ouslywithoutcausinganycomplications.However,complicationssecondarytosharpesophagealforeignbodyinjuryhavebeenre-portedsuchasesophagealperforation,fistulae,andpleuralempy-ema[16].Pneumomediastinumisnormallycomplicatedbyeitheresophagealorpulmonaryrupture,andesophagealrupturecanoccurasaresultofforeignbodiesortraumainthesystem[17].InapreviousretrospectiveAENcaseseries,themostseriouscompli-cationsreportedweremediastinitisandpneumomediastinum[1].Ourpatientalsohadriskfactorsincludingoldage,diabetesmelli-tus,prolongedhypotensionandsepsis.
SeveralviralorfungalinfectionssuchascytomegalovirusandCandida albicanscancauseAEN[8,11,18].However,immunohis-tochemicalstainingforcytomegalovirusandPeriodicacid-Schiffstainingforfungalinfectionswerenegativeinourcase.
ThetreatmentofAENissupportive,includingadequatehydra-tionandtheuseofprotonpumpinhibitorsinmostcases.Treat-mentshouldalsoaddressanycomorbidities.
TheprognosisofAENpatientsisvariableanddependsonun-derlyingclinicalconditions.DeathssecondarytoAENoccurinlessthan6%ofcases[9].
Inconclusion,wepresentthefirstcaseofAENassociatedwithesophagealforeignbodyinjuryandthedevelopmentofpneumo-mediastinuminKorea.
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