Acute Esophageal Necrosis Following Cardiac Arrest in the Setting of Retroperitoneal Fibrosis-Associated Gastric Outlet Obstruction

CASE REPORT

A 66-year-old woman with bilateral ureteral obstruction secondary to retroperitoneal fibrosis (RPF) requiring nephrostomy tubes presented with vomiting and abdominal pain. She suffered torsades de pointes cardiac arrest (QTc 641 ms) provoked by QT-prolonging medications and electrolyte derangements. Her course progressed from arrest (day 0) to acute esophageal necrosis diagnosis (day 8), duodenal obstruction identification (days 14–17), and surgical bypass (day 24).

Esophagogastroduodenoscopy (EGD) on day 8 revealed circumferential black, necrotic esophageal mucosa (Figure 1). Biopsies were deferred given perforation risk. Repeat EGD on day 14 demonstrated healing esophageal ulceration and complete obstruction at the duodenal bulb apex (Figure 2). Computed tomography showed a distended, fluid-filled stomach with contrast failing to pass beyond the duodenal bulb (Figure 3). A third EGD on day 17 using a pediatric colonoscope traversed severe stenosis extending continuously from D2 through D4; endoscopic ultrasound excluded malignancy (Figure 4). Intraoperatively, fibrosis in the retroperitoneum was felt to account for near-complete duodenal obstruction, necessitating gastrojejunostomy and Roux-en-Y choledochojejunostomy.

Figure 1.

Esophagogastroduodenoscopy on hospital day 8 demonstrating acute esophageal necrosis. (A) Lower third of esophagus showing circumferential black, necrotic mucosa with friability and ulceration. (B) Middle third of esophagus with diffuse necrotic changes (arrow) and loss of normal vascular pattern. (C) Retroflexed view of the cardia demonstrating extension of necrotic injury to the gastroesophageal junction.

Figure 2.

Repeat esophagogastroduodenoscopy on hospital day 14. (A and B) Middle and lower thirds of esophagus demonstrating healing ulcerated mucosa with residual severe esophagitis. (C) Duodenal bulb showing a 15 mm clean-based serpiginous ulcer (arrow) with severe stenosis at the apex.

Figure 3.

(A) Axial contrast-enhanced computed tomography of the abdomen on hospital day 15 demonstrating a markedly distended, fluid-filled stomach (arrow) with oral contrast not passing beyond the duodenal bulb. (B) Sagittal image shows marked gastric distension with retained oral contrast and an abrupt cutoff at the level of the proximal duodenum (arrow).

Figure 4.

Esophagogastroduodenoscopy with endoscopic ultrasound on hospital day 17. (A) Distal esophagus demonstrating severe esophagitis with friable, erythematous mucosa but no active bleeding (arrow). (B) Forrest class III ulcer (15 mm) in the duodenal bulb with clean fibrinous base. (C) Severe stenosis (arrow) with marked edema just distal to the duodenal bulb ulcer. (D) Edematous duodenal mucosa in the third/fourth portion of the duodenum, traversed using a pediatric colonoscope; the stenosis was continuous from D2 through D4.

This case illustrates a potential “two-hit” mechanism contributing to acute esophageal necrosis: ischemic injury from cardiac arrest and prolonged gastric acid exposure from RPF-associated gastric outlet obstruction.^1–3 Definitive RPF classification was limited by absent retroperitoneal biopsy, though IgG4 and tumor markers were normal.

DISCLOSURES

Author contributions: I. Antony: drafting of manuscript, data collection. V. Rifat and M. Antony: literature review. Y. Agha: critical revisions, supervision, final approval. Y. Agha is the article guarantor.

Financial disclosure: None to report.

Previous presentation: Case presented at the American College of Gastroenterology Annual Scientific Meeting, October 24-29, 2025; Phoenix, Arizona.

Informed consent was obtained for this case report.