Cases and Techniques Library (CTL) E279

Acute esophageal necrosis: possible association with terlipressin

Fig. 3 View of the lower during an Fig. 1 Endoscopic views in a 75-year-old man with and showing: a black mucosa performed a month after discharge consistent with acute esophageal necrosis; b an exposed vessel in an ulcer at the cardia. showing a Schatzki ring.

endoscopy 8 months later showed no abnormal esophageal findings. Acute esophageal necrosis is character- ized by a circumferential mucosal black- ening involving the distal esophagus and occasionally extending upstream that stops abruptly at the gastroesophageal junction [1]. Ulceration of the cardia, as in this case, is uncommon; however, sim- ilar cases have been reported [2]. Ischemia, impaired mucosal defenses, and Fig. 2 Views during a second endoscopy performed after 8 days showing: a a clear margin between chemical insult seem to contribute to its the intact proximal esophagus and the damaged middle third of the esophagus; b a stricture of the pathogenesis [3]. The distal esophagus cardia. has been shown to be less vascularized in angiographic studies [2,3], arguably making it susceptible to local hypoper- A 75-year-old man was admitted to our tending circumferentially in which there fusion caused by low splanchnic blood department with abdominal pain, hema- was a large exposed vessel (●" Fig. 1b), flow. In the case described, such a state temesis, and melena. His significant med- which was treated by application of a could have resulted from hemorrhage ical history included erosive , Hemoclip.The and and hypotension. alcohol-related chronic , and were intact. Brushings were negative for Furthermore, because of the signs of liver chronic . He was not receiving cytomegalovirus. Broad-spectrum anti- dysfunction and the history of alcohol any medication. His blood pressure was biotics, antifibrinolytic drugs, and paren- abuse, which suggested variceal bleeding, low (80/50mmHg); results of laboratory teral nutrition were commenced; terli- the patient received terlipressin, a testing showed macrocytic anemia and pressin was stopped. splanchnic vasoconstrictor that may have This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. liver dysfunction (hemoglobin 11.8 g/dL, Endoscopy at day 8 showed a clear margin reduced microcirculatory perfusion, fur- mean cell volume [MCV] 106.4 fL, interna- between the intact proximal esophagus ther contributing to the local ischemia tional normalized ratio [INR] 1.53). After a and its lower portion (●" Fig.2a). The lu- [4]. Although cutaneous necrosis follow- second episode of hematemesis, his he- minal circumference decreased cranio- ing terlipressin treatment has been re- moglobin dropped to 8.9g/dL and he was caudally, ending in a stricture at the car- ported [5], this is the first reported case treated by infusion of a colloidal solution, dia (●" Fig. 2b). At day 16, the distal of a possible association with acute two units of packed red blood cells, a pro- esophagus appeared stenotic but was pas- esophageal necrosis. ton pump inhibitor, and terlipressin (2mg sable and enteral nutrition was resumed. every 4 hours). The patient was discharged 25 days after Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH Endoscopy showed a black mucosa admission. A month later, endoscopy (●" Fig.1a) that started from the upper revealed almost complete restoration of Competing interests:None esophagus and ended abruptly at the car- the mucosa. Notably, at the cardia we ob- dia. At that level, we identified an ulcer ex- served a Schatzki ring (●" Fig.3). A further

Efthymakis Konstantinos et al. Acute esophageal necrosis … Endoscopy 2014; 46: E279–E280 E280 Cases and Techniques Library (CTL)

Konstantinos Efthymakis, References Bibliography Chiara Massacesi, Angelo Milano, 1 Moretó M, Ojembarrena E, Zaballa M et al. DOI http://dx.doi.org/ Francesco Laterza, Emanuele Tafuri, Idiopathic acute esophageal necrosis: not 10.1055/s-0034-1365789 necessarily a terminal event. Endoscopy Endoscopy 2014; 46: E279–E280 Francesco Cipollone, Matteo Neri 1993; 25: 534–538 © Georg Thieme Verlag KG Department of Medicine and Ageing 2 Burtally A, Gregoire P. Acute esophageal Stuttgart · New York Sciences, Section of Internal Medicine necrosis and low-flow state. Can J Gastroen- ISSN 0013-726X terol 2007; 21: 245–247 and Center for Excellence on Ageing 3 Gurvits GE. Black esophagus: acute esopha- “ ’ ” (Ce.S.I.), G. D Annunzio University geal necrosis syndrome. World J Gastroen- Corresponding author and Foundation, Chieti, Italy terol 2010; 16: 3219–3225 Matteo Neri, MD 4 Asfar P, Bracht H, Radermacher P. Impact of U.O. di Gastroenterologia ed Endoscopia Digestiva vasopressin analogues on the gut mucosal Università G. D’Annunzio microcirculation. Best Pract Res Clin Anaes- Ospedale SS Annunziata – thesiol 2008; 22: 351 358 Chieti 5 Lu YY, Wei KC, Wu CS. Terlipressin-induced Italy extensive skin necrosis: a case report and Fax: +39-0871-357446 published work review. J Dermatol 2012; [email protected] 39: 866–868 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Efthymakis Konstantinos et al. Acute esophageal necrosis… Endoscopy 2014; 46: E279–E280