Acute Necrotizing Esophagitis: Case Reports and Review of Literature

ABSTRACT:


Background:
Acute esophageal necrosis (AEN) is also known as black esophagus or acute necrotizing esophagitis. It is a rare esophageal disease with unknown etiology, raising attention in recent decades. Its diagnosis is made by upper gastrointestinal endoscopy or pathologic study.


Objective:
We want to share our experience in treatment and reconstruction of necrotizing esophagitis. The images are described and the literature is reviewed.


Case Presentation:
Case 1: A 49-year-old man with history of hypertension and diabetes, came to our hospital after suffering from right chest pain with dysphagia for one week. Chest CT performed at emergency service showed rupture of esophageal mucosa with intramural esophageal dissection noted from thoracic inlet level, all the way to esophago-gastric junction, with infective fluid and gas collection in the intramural false lumen. Abscess formation up to 10 x 6 x 4 cm was noted in the right side of mediastinum, consistent with mediastinitis. Firstly, he received thoracoscopic mediastinotomy decortication for infection control then total esophagectomy and cervical esophagostomy. Meanwhile decompressive gastrostomy and feeding jejunostomy were also performed. Pathologic study showed necrotizing inflammation with perforation. Three months later he received reconstruction with gastric pull-up. However, a defect at posterior wall of cervical esophagus developed 1 month later. Thus, the plastic surgeon took over and free jejunum flap for reconstruction of cervical esophagus was performed. Patient has prompt recovery with smooth swallowing and nutrition status.

Case 2: A 17-year-old female was followed for 15 years post esophagus reconstruction due to pharyngitis causing esophagus destruction. She has pharyngitis at 6 months of age which extended to the esophagus causing esophageal necrosis. She received free jejunum flap and pedicle colon flap reconstruction at age 2. Now, after 15 years of flap follow up her esophagography showed smooth swallowing. She has good nutrition status and normal development so far.

 

Conclusion:

We use free jejunum flap for cervical esophagus. It provides good motility for initiation of food passage and can be done safely both in children and adults. The long-term durability of jejunum for esophagus reconstruction is well established. The jejunum mucosa retains its original features with no metaplasia. For the thoracic part of esophagus, either gastric pull-up or pedicled colon flap is a good option

Key words: Acute necrotizing esophagitis, free jejunum flap, gastric pull-up, pedicled colon flap