Barrett esophagus and unexpected death

Barrett esophagus is characterized by the presence of columnar mucosa in the lower esophagus in continuity with gastric mucosa. Complications include ulceration and adenocarcinoma. Although sudden and unexpected death is not a usual outcome, the case of a 63-year-old man is presented who died unexpectedly following perforation of an ulcerated Barrett esophagus, with development of an esophagopleural fistula. Sudden and/or unexpected death in individuals with Barrett esophagus may result from hemorrhage due to erosion into mural vessels, the aorta or heart, or from penetration into the pleural space, trachea, bronchi, and pericardial sac, with the development of tension pyopneumothorax, bronchial fistula, and mediastinitis. Ulceration of the lower esophagus at autopsy should prompt consideration of the possibility of a Barrett esophagus and initiate careful dissection/examination of the surrounding mediastinal tissues and vessels.