Upper Gastrointestinal Bleeding in a Patient with Liver Cirrhosis: Gastroesophageal Varices Are not Always to Blame

A 45-year-old male with active alcoholism and liver cirrhosis was brought to emergency room with hypovolemic shock in context of diarrhea and melena. He presented with hemodynamic instability, hyperlactatemia and anemia. Aggressive supportive therapy with vasopressor support, packed red blood cell transfusion and intra-venous proton pump inhibitor was started. Upper digestive endoscopy revealed diffuse circumferential black discoloration of middle and distal esophagus with areas of linear ulceration and mucosal sloughing, consistent with acute esophageal necrosis. There was no evidence of esophageal varices. Abdominal computerized tomography scan revealed concomitant extensive bowel ischemia involving small and large bowel. Despite supportive measures, the disease had a fulminant evolution and the patient died after a few hours. Acute esophageal necrosis is defined endoscopically by diffuse and circumferential black mucosal discoloration of distal esophagus with abrupt transition at gastroesophageal junction and variable proximal extension. It is more common in older males with general debilitation and multiple comorbidities and typically presents with hematemesis or melena. An association with liver cirrhosis is well established, probably related to a state of malnutrition that decreases esophageal mucosal defenses and impairs regenerative ability. This case demonstrates that, although gastroesophageal varices and peptic ulcer bleeding are the most common sources of gastrointestinal bleeding in cirrhotic patients, acute esophageal necrosis must also be considered, particularly in the setting of hemodynamic instability.