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Colón AR, Kamboj AK, Hagen CE, Rattan P, Coelho-Prabhu N, Buttar NS, Bruining DH, Storm AC, Larson MV, Viggiano TR, Wong Kee Song LM, Wang KK, Iyer PG, Katzka DA, Leggett CL. Acute Esophageal Necrosis: A Retrospective Cohort Study Highlighting the Mayo Clinic Experience. Mayo Clin Proc 2022; 97:1849-1860. [PMID: 35779957 DOI: 10.1016/j.mayocp.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/07/2022] [Accepted: 03/11/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To describe the clinical, endoscopic, and histologic features in patients with acute esophageal necrosis (AEN). PATIENTS AND METHODS In this retrospective cohort study, patients who were diagnosed as having AEN at Mayo Clinic sites in Minnesota, Florida, and Arizona between January 1, 1996, and January 31, 2021, were included. Data were collected on patient clinical characteristics and endoscopic and pathologic findings. RESULTS The study included 79 patients with AEN with a median (range) age of 64 years (12 to 91 years); 53 (67.1%) were men. Predominant presenting symptoms were hematemesis (49 of 79 [62.0%]), abdominal pain (29 [36.7%]), and melena (20 [25.3%]). Shock was the triggering event for AEN in 49 (62.0%). The 30- and 90-day mortality were 24.0% (19 of 79) and 31.6% (25), respectively. The presence of coexisting infection or bacteremia was significantly associated with 90-day mortality (P<.01). Endoscopically, involvement of the distal third only, distal two-thirds only, and entire esophagus was observed in 31.6% (24 of 76), 39.5% (30), and 29.0% (22), respectively. The length of esophageal involvement correlated with duration of hospitalization (P=.05). The endoscopic appearance of the esophageal mucosa ranged from predominantly white (21 of 44 [47.7%]) to mixed white and black (13 [29.6%]) to predominantly black (10 [22.7%]), and sloughing was present in 18 (40.9%). In the 26 patients with histopathologic findings available for review, 25 (96.1%) had necrosis and/or ulceration with abundant pigmentation. Among the 79 patients, 39 (49.4%) had a follow-up esophagogastroduodenoscopy; 26 of these 39 patients (66.7%) had resolution while 5 had persistent AEN, 4 of whom had improvement. Esophageal strictures developed in 7 of the 39 patients (18.0%). CONCLUSION Acute esophageal necrosis is a serious condition observed in critically ill patients. Its endoscopic appearance can be highly variable. In patients with an unclear diagnosis, esophageal biopsies may be helpful given the characteristic histologic findings.
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Affiliation(s)
| | - Amrit K Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Catherine E Hagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Puru Rattan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Navtej S Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mark V Larson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Thomas R Viggiano
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Papakonstantinou NA, Patris V, Antonopoulos CN, Samiotis I, Argiriou M. Oesophageal necrosis after thoracic endovascular aortic repair: a minimally invasive endovascular approach-a dramatic complication. Interact Cardiovasc Thorac Surg 2019; 28:9-16. [PMID: 29945176 DOI: 10.1093/icvts/ivy193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 05/18/2018] [Indexed: 11/14/2022] Open
Abstract
There are few cases in the literature reporting dysphagia caused by oesophageal compression by the aorta due to acute or chronic aortic pathology. This type of dysphagia is called dysphagia aortica. Thoracic endovascular aortic repair is nowadays the treatment of choice for anatomically suitable patients experiencing complicated Type B aortic dissection. Oesophageal necrosis is a rare but fatal complication following thoracic endovascular aortic repair. Extrinsic oesophageal compression by the thrombosed aneurysmal sac, a mediastinal haematoma or extensive thrombosis in the false lumen of a dissected aorta and acute vascular occlusion of the oesophageal supply are possible mechanisms. When oesophageal necrosis is suspected, endoscopic examination and computed tomography imaging should be performed repeatedly. Oesophagoscopy will confirm the diagnosis revealing a black, diffusely necrotic and ulcerated oesophageal mucosa. It is critical to intervene before full-thickness oesophageal wall necrosis and mediastinitis occur. Guidelines are absent because of the rarity of this complication. Moreover, lack of a large series does not permit the establishment of guidelines either. However, oesophagectomy of the impaired oesophagus is the only chance for survival. Unfortunately, survival rates are disappointing. Prevention and awareness is the cornerstone of success. Early endoscopic examination when oesophageal necrosis is suspected due to even minimal symptoms will detect this fatal menace on time.
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Affiliation(s)
- Nikolaos A Papakonstantinou
- Department of Cardiovascular and Thoracic Surgery, General Hospital of Athens "Evangelismos", Athens, Greece
| | - Vasileios Patris
- Department of Cardiovascular and Thoracic Surgery, General Hospital of Athens "Evangelismos", Athens, Greece
| | - Constantine N Antonopoulos
- Department of Cardiovascular and Thoracic Surgery, General Hospital of Athens "Evangelismos", Athens, Greece
| | - Ilias Samiotis
- Department of Cardiovascular and Thoracic Surgery, General Hospital of Athens "Evangelismos", Athens, Greece
| | - Mihalis Argiriou
- Department of Cardiovascular and Thoracic Surgery, General Hospital of Athens "Evangelismos", Athens, Greece
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Earl-Royal E, Nguyen PD, Alvarez A, Gharahbaghian L. Detection of Type B Aortic Dissection in the Emergency Department with Point-of-Care Ultrasound. Clin Pract Cases Emerg Med 2019; 3:202-207. [PMID: 31404375 PMCID: PMC6682226 DOI: 10.5811/cpcem.2019.5.42928] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/08/2019] [Accepted: 05/16/2019] [Indexed: 11/17/2022] Open
Abstract
Aortic dissection (AD) is a rare, time-sensitive, and potentially fatal condition that can present with subtle signs requiring timely diagnosis and intervention. Although definitive diagnosis is most accurately made through computed tomography angiography, this can be a time-consuming study and the patient may be unstable, thus preventing the study’s completion. Chest radiography (CXR) signs of AD are classically taught yet have poor diagnostic reliability. Point-of-care ultrasound (POCUS) is increasingly used by emergency physicians for the rapid diagnosis of emergent conditions, with multiple case reports illustrating the sonographic signs of AD. We present a case of Stanford type B AD diagnosed by POCUS in the emergency department in a patient with vague symptoms, normal CXR, and without aorta dilation. A subsequent review of CXR versus sonographic signs of AD is described.
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Affiliation(s)
- Emily Earl-Royal
- Stanford School of Medicine, Department of Emergency Medicine, Palo Alto, California
| | - Phi D Nguyen
- Kaiser Permanente Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
| | - Al'ai Alvarez
- Stanford School of Medicine, Department of Emergency Medicine, Palo Alto, California
| | - Laleh Gharahbaghian
- Stanford School of Medicine, Department of Emergency Medicine, Palo Alto, California
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Joubert KD, Betzold RD, Steliga MA. Successful Treatment of Esophageal Necrosis Secondary to Acute Type B Aortic Dissection. Ann Thorac Surg 2017; 102:e547-e549. [PMID: 27847078 DOI: 10.1016/j.athoracsur.2016.04.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 03/19/2016] [Accepted: 04/25/2016] [Indexed: 01/27/2023]
Abstract
Esophageal necrosis after descending aortic dissection has been described but with no reports of successful treatment. A 66-year-old man with aortic dissection extending from the left subclavian artery through the common iliac arteries subsequently experienced esophageal necrosis. He underwent thoracic esophagectomy, cervical end esophagostomy, and open gastrostomy tube placement. Gastrointestinal continuity was established with a gastric tube conduit in the substernal plane. An oral diet was tolerated after reconstruction. Treatment of esophageal necrosis after aortic dissection may require esophageal diversion and esophagectomy. Esophageal continuity can later be restored while avoiding the posterior mediastinum.
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Affiliation(s)
- Kyla D Joubert
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Richard D Betzold
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Matthew A Steliga
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Division of Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Abou-Al-Shaar H, Zaza KJ, Sharif MA, Koussayer S. Free Esophageal Perforation Following Hybrid Visceral Debranching and Distal Endograft Extension to Repair a Ruptured Thoracoabdominal Aortic Aneurysm. Vasc Endovascular Surg 2016; 50:502-506. [PMID: 27625002 DOI: 10.1177/1538574416664441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Free esophageal perforation following a hybrid visceral debranching and distal endograft extension to repair a ruptured thoracoabdominal aortic aneurysm (TAAA) is a rare complication. The authors report a 56-year-old male who underwent elective thoracic endovascular aortic repair of a thoracic aneurysm. Four and a half years later, he presented with a new aneurysm extending from the distal end of the thoracic stent graft to the aortic bifurcation involving all the visceral arterial branches. The TAAA ruptured while he was awaiting an elective repair, and as a result, he underwent an emergency hybrid procedure. This involved debranching the visceral arterial branches including autotransplantation of the left kidney and distal endograft extension. Postoperatively, he developed free esophageal perforation secondary to ischemic necrosis requiring esophageal resection and gastric pull-up. The patient was well 6 months after the gastrointestinal restorative procedure. Thus, esophageal perforation following an emergency hybrid repair of ruptured TAAA is a rare complication, and a successful outcome depends on early recognition and surgical exclusion of the ruptured viscus.
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Affiliation(s)
- Hussam Abou-Al-Shaar
- Division of Vascular and Endovascular Surgery, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Khaled Juan Zaza
- Division of Vascular and Endovascular Surgery, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Muhammad Anees Sharif
- Division of Vascular and Endovascular Surgery, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Samer Koussayer
- Division of Vascular and Endovascular Surgery, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Choi JS, Oh SJ, Sung YW, Moon HJ, Lee JS. Early Experiences with the Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:73-9. [PMID: 27064672 PMCID: PMC4825906 DOI: 10.5090/kjtcs.2016.49.2.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/12/2016] [Accepted: 02/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to report our early experiences with the endovascular repair of ruptured descending thoracic aortic aneurysms (rDTAAs), which are a rare and life-threatening condition. METHODS Among 42 patients who underwent thoracic endovascular aortic repair (TEVAR) between October 2010 and September 2015, five patients (11.9%) suffered an rDTAA. RESULTS The mean age was 72.4±5.1 years, and all patients were male. Hemoptysis and hemothorax were present in three (60%) and two (40%) patients, respectively. Hypovolemic shock was noted in three patients who underwent emergency operations. A hybrid operation was performed in three patients. The mean operative time was 269.8±72.3 minutes. The mean total length of aortic coverage was 186.0±49.2 mm. No 30-day mortality occurred. Stroke, delirium, and atrial fibrillation were observed in one patient each. Paraplegia did not occur. Endoleak was found in two patients (40%), one of whom underwent an early and successful reintervention. During the mean follow-up period of 16.8±14.8 months, two patients died; one cause of death was a persistent type 1 endoleak and the other cause was unknown. CONCLUSION TEVAR for rDTAA was associated with favorable early mortality and morbidity outcomes. However, early reintervention should be considered if persistent endoleak occurs.
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Affiliation(s)
- Jae-Sung Choi
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Se Jin Oh
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Yong Won Sung
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Hyun Jong Moon
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Jung Sang Lee
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
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Minami T, Imoto K, Uchida K, Karube N, Yasuda S, Choh T, Suzuki S, Masuda M. Thoracic Endovascular Aortic Repair for Ruptured Descending Thoracic Aortic Aneurysm. J Card Surg 2014; 30:163-9. [DOI: 10.1111/jocs.12499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tomoyuki Minami
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
- Cardiovascular Surgery; Yokohama Municipal Citizen's Hospital; Yokohama Kanagawa Japan
| | - Kiyotaka Imoto
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Keiji Uchida
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Norihisa Karube
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Shota Yasuda
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Tomoki Choh
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Shinichi Suzuki
- Department of Surgery; Yokohama City University Hospital; Yokohama Kanagawa Japan
| | - Munetaka Masuda
- Department of Surgery; Yokohama City University Hospital; Yokohama Kanagawa Japan
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van de Wal-Visscher E, Nieuwenhuijzen GAP, Nieuwenhuijsen GAP, van Sambeek MRHM, Haanschoten M, Botman KJ, de Hingh IHJT. Type B aortic dissection resulting in acute esophageal necrosis. Ann Vasc Surg 2011; 25:837.e1-3. [PMID: 21620661 DOI: 10.1016/j.avsg.2010.12.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 10/20/2010] [Accepted: 12/22/2010] [Indexed: 01/27/2023]
Abstract
In the present article, we report a case in which acute esophageal necrosis (AEN) of the intrathoracic esophagus was caused by extensive thrombosis in the false lumen of an aortic dissection, thereby occluding the blood flow to the intercostal arteries and thus the esophagus. According to the previously published data, AEN after aortic dissection is very rare and usually fatal. Besides esophageal ischemia secondary to arterial occlusion, direct extrinsic compression of the arteriovenous network surrounding the esophagus, caused by the traumatic pathology of the aorta, by extensive extravasation may also cause AEN. AEN is most commonly confirmed by esophagoscopy, typically showing a black, diffusely necrotic, and ulcerated esophageal mucosa.
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10
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Esophageal Necrosis After Endoprosthesis for Ruptured Thoracoabdominal Aneurysm Type I: Can Long-Segment Stent Grafting of the Thoracoabdominal Aorta Induce Transmural Necrosis? Ann Vasc Surg 2010; 24:1137.e7-12. [DOI: 10.1016/j.avsg.2010.04.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 04/01/2010] [Accepted: 04/12/2010] [Indexed: 11/23/2022]
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11
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Carneiro M, Lescano M, Romanello L, Modena J, Carneiro F, Ramalho L, Martinelli A, Franca A. ACUTE ESOPHAGEAL NECROSIS. Dig Endosc 2005. [DOI: 10.1111/j.1443-1661.2005.00464.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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12
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Park NH, Kim JH, Choi DY, Choi SY, Park CK, Lee KS, Han SW, Yoo YS. Ischemic Esophageal Necrosis Secondary to Traumatic Aortic Transection. Ann Thorac Surg 2004; 78:2175-8. [PMID: 15561068 DOI: 10.1016/j.athoracsur.2003.07.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2003] [Indexed: 11/27/2022]
Abstract
Esophageal necrosis with perforation secondary to traumatic aortic transection is extremely rare but usually fatal. A 47-year-old man complained of sudden swallowing difficulty 6 days after blunt trauma. Computed tomography showed a ruptured aorta and the midesophagus shifted to the right side with luminal obliteration because of the ruptured aorta. After primary repair of the partially transected aorta, unexpected mediastinitis because of esophageal perforation was noted. Upper endoscopy showed midesophageal ulceration, necrosis, and perforation. Biopsy samples were consistent with ischemia. The possibility of direct esophageal trauma or intraoperative esophageal injury was ruled out. Esophageal exclusion with thoracoscopic decortication and multiple antibiotics were ineffective, and the patient eventually died. Ischemic esophageal necrosis caused by mechanical compression can occur in a traumatic aortic transection. Dysphagia, when present with radiologic signs, indicates a displaced and compressed esophagus. In spite of aggressive surgical and medical treatment for a perforated esophagus, the prognosis remains poor.
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Affiliation(s)
- Nam-Hee Park
- Department of Thoracic and Cardiovascular Surgery, Keimyung University, Dongsan Medical Center, Daegu, South Korea
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Khan AM, Hundal R, Ramaswamy V, Korsten M, Dhuper S. Acute esophageal necrosis and liver pathology, a rare combination. World J Gastroenterol 2004; 10:2457-8. [PMID: 15285044 PMCID: PMC4576312 DOI: 10.3748/wjg.v10.i16.2457] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acute esophageal necrosis (AEN) or “black esophagus” is a clinical condition found at endoscopy. It is a rare entity the exact etiology of which remains unknown. We describe a case of ‘black esophagus’, first of its kind, in the setting of liver cirrhosis and hepatic encephalopathy.
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Ben Soussan E, Savoye G, Hochain P, Hervé S, Antonietti M, Lemoine F, Ducrotté P. Acute esophageal necrosis: a 1-year prospective study. Gastrointest Endosc 2002; 56:213-7. [PMID: 12145599 DOI: 10.1016/s0016-5107(02)70180-6] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A prospective 1-year study was conducted to assess the frequency, clinical spectrum, histologic description, and follow-up of acute esophageal necrosis unrelated to ingestion of caustic or corrosive agents. METHODS The diagnosis of acute esophageal necrosis was based on a diffusely black esophagus at endoscopy and typical histologic features of diffuse mucosal and submucosal necrosis. Ingestion of caustic and corrosive agents was excluded in all patients. Medical history, associated diseases, and clinical symptoms were recorded for each patient. Nutritional status was evaluated based on clinical and biochemical parameters. Treatment included short-term parenteral nutrition and intravenous administration of a pump proton inhibitor. A second endoscopy was performed when possible at 2 weeks after presentation to assess regression of acute esophageal necrosis. RESULTS Among 3900 patients who underwent EGD, 8 (0.2%) with acute esophageal necrosis were identified. Nutritional status was poor for 6 patients. Complete resolution of acute esophageal necrosis without further recurrence was observed in 4. No esophageal strictures appeared during follow-up. Four patients died, but no death was directly related to acute esophageal necrosis. CONCLUSION Acute esophageal necrosis is not as infrequent an endoscopic finding as has been reported. Acute esophageal necrosis appears to be associated with poor general health status and is not a purely local phenomenon.
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Affiliation(s)
- Emmanuel Ben Soussan
- Digestive Tract Research Group and Department of Pathology, Rouen University Hospital, Rouen Cedex, France
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