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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: leehyuk@yuhs.acReceived:  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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