# Acute esophageal necrosis following cardiac arrest: A rare and lethal syndrome with diagnostic challenges

## TL;DR

A rare and deadly condition called acute esophageal necrosis is linked to cardiac arrest and requires urgent endoscopic diagnosis and treatment.

## Contribution

This case introduces emergent upper GI endoscopy as a novel diagnostic method for AEN in cardiac arrest scenarios.

## Key findings

- Endoscopy is crucial for diagnosing AEN due to CT's limited specificity.
- AEN has a high mortality rate of 32% despite aggressive treatment.
- Early identification and multidisciplinary care are essential to improve outcomes.

## Abstract

Acute esophageal necrosis (AEN) is a condition characterized by the necrosis of the distal portion of the esophageal mucosa. Risk factors predisposing to this condition are associated to compromised vascular perfusion (e.g. diabetes mellitus, chronic kidney disease, advanced age, and hypertension, shock states). Complications of AEN can be severe including UGI stricture, perforation and overall increased mortality. The true incidence of AEN remains uncertain due to potential subclincal presentations and early resolution.

The case outlined involves a 66-years-old obese male with history of alcoholism and lymph-edema of the left leg who presented to the emergency department with hematemesis, haemodynamic instability and impaired consciousness. Shortly after initial assessment, the patient went into cardiac arrest with pulse-less electrical activity (PEA). Return of spontaneous circulation (ROSC) was achieved following instigation of ALS protocol, fluid resuscitation and the administration of a total of 5 mg of adrenaline. Following stabilization, a CT scan was performed which reported a moderately enlarged esophagus with a thickened wall, liquid hypodense material within the esophagus and stomach, and liver cirrhosis. The emergent esophagogastroduodenoscopy (EGDS) revealed extensive mucosal findings indicative of diffuse necrosis with initial scarring, which was later diagnosed as AEN. The patient unfortunately deceased in ICU after developing progression of the AEN, post-cardiac arrest syndrome and liver failure.

The presented case highlights several crucial clinical issues and management problems related to AEN. To diagnose AEN, EGDS is still the gold-standard since it allows direct inspection of the esophageal mucosal layer. The management of AEN necessitates a multidisciplinary approach that includes aggressive resuscitation, treatment of underlying comorbidities, and supportive care (e.g. proton pump inhibitors). The mortality rate for AEN remains high despite improvements in diagnosis and treatment highlighting the need to recognize this condition early and intervene promptly in the patients affected. Moreover, long-term sequelae like stricture formation of the esophagus and impaired esophageal motility may contribute to morbidity requiring continuos monitoring. Therefore, to optimize outcomes while reducing complications among affected patients, prompt identification associated with appropriate medical measures are essential. More research needs to be done aiming to better understand the pathophysiology of AEN thereby identifying strategies for its prevention or cure.

AEN is a rare syndrome characterized by upper gastrointestinal bleeding and hypoxic damage of the esophageal mucosa, often associated with ischemia, gastric outlet obstruction, and compromised protective barriers. Treatment involves aggressive resuscitation, proton pump inhibitors, and monitoring for infection or perforation. However, despite intensive efforts, the mortality rate for AEN remains high at 32 %.

•Critical Patient: 66-year-old obese male with possible alcoholic liver disease and recent left leg lymphedema. Presented with coffee ground emesis and signs of hypoperfusion.•Endoscopy & Treatment: Emergent upper GI endoscopy revealed pale, granular esophageal mucosa with black membranes, indicating diffuse necrosis with initial scarring. Treated with pantoprazole, vasopressors, transfusions, and renal therapy due to liver failure and coagulation deficit. Follow-up EGD showed advanced scarring.•Implications: Acute Esophageal Necrosis (AEN) links to ischemia, gastric obstruction, and compromised barriers. Diagnosis through endoscopy is crucial due to CT's limited specificity. Despite aggressive treatment, mortality rates are high, tied to underlying conditions.•Novel Research: This study sheds light on AEN's links to cardiac arrest, ischemia, and barriers. It introduces innovative diagnostic methods, particularly emergent upper GI endoscopy, revealing distinct mucosal changes of necrosis with initial scarring. Advancing understanding in cardiac arrest scenarios and diagnostic approaches for this rare syndrome is crucial.

Critical Patient: 66-year-old obese male with possible alcoholic liver disease and recent left leg lymphedema. Presented with coffee ground emesis and signs of hypoperfusion.

Endoscopy & Treatment: Emergent upper GI endoscopy revealed pale, granular esophageal mucosa with black membranes, indicating diffuse necrosis with initial scarring. Treated with pantoprazole, vasopressors, transfusions, and renal therapy due to liver failure and coagulation deficit. Follow-up EGD showed advanced scarring.

Implications: Acute Esophageal Necrosis (AEN) links to ischemia, gastric obstruction, and compromised barriers. Diagnosis through endoscopy is crucial due to CT's limited specificity. Despite aggressive treatment, mortality rates are high, tied to underlying conditions.

Novel Research: This study sheds light on AEN's links to cardiac arrest, ischemia, and barriers. It introduces innovative diagnostic methods, particularly emergent upper GI endoscopy, revealing distinct mucosal changes of necrosis with initial scarring. Advancing understanding in cardiac arrest scenarios and diagnostic approaches for this rare syndrome is crucial.