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Answer 2
  1. Strict NPO status, aggressive acid suppression, and observation. The patient has likely sustained an ischemic injury to the esophagus as a result of a prolonged surgery with associated hypotension in the setting of baseline cardiovascular disease. The endoscopic findings are known as “black esophagus” (Figure). This entity is relatively rare because of the dual segmental and intramural blood supply of the esophagus. In patients who do not have evidence of perforation, treatment is supportive with cessation of oral intake and acid suppression. A nasogastric tube is contraindicated in this setting, as it could perforate the esophagus during placement, and the patient only had 1 episode of coffee-ground emesis. No surgery is required at present because the patient is stable and would be a high-risk candidate for another surgical intervention. A barium swallow would not add to data obtained at endoscopy, especially since the patient has no signs of perforation. While some infections can cause black esophagus, aggressive esophageal biopsies should be avoided given the increased risk of iatrogenic perforation.

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