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Ziegler PE, Rosario Lora D, DeMeo M. An Unusual Case of Black Esophagus. ACG Case Rep J 2023; 10:e01202. [PMID: 37954931 PMCID: PMC10635593 DOI: 10.14309/crj.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Patients with acute esophageal necrosis often present with hematemesis and upper gastrointestinal bleeding. Our case report describes a patient's incidental discovery of black esophagus without recent hemodynamic instability, symptoms, or evidence of blood loss anemia. As illustrated in this case, it is important to recognize these findings in patients without classic signs and symptoms to act promptly and prevent tissue ischemia or perforation. Early recognition can also help reduce the risk of long-term complications such as stricture formation. Thus, a high index of suspicion is essential for the diagnosis of acute esophageal necrosis.
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Affiliation(s)
| | | | - Mark DeMeo
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, Rush University, Chicago, IL
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2
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Deliwala SS, Lakshman H, Congdon DD, Elbedawi MM, Bachuwa G, Gurvits GE. Black Esophagus in the Setting of Alcohol Abuse after External Beam Radiation. Case Rep Gastroenterol 2020; 14:443-447. [PMID: 32999646 PMCID: PMC7506255 DOI: 10.1159/000508852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/19/2020] [Indexed: 11/21/2022] Open
Abstract
Acute esophageal necrosis (AEN), black esophagus, or Gurvits syndrome is a rare clinical disorder characterized by a striking endoscopic appearance of necrotic esophageal mucosa, universally affecting the distal esophagus and ending abruptly at the gastroesophageal junction. It has been gaining traction as a demonstrable cause of upper gastrointestinal bleeding in the 21st century. Its pathophysiology is multifactorial affecting men and the elderly disproportionally, with a mortality rate nearing 36%. AEN has been associated with numerous conditions in the past, and we aim to present an unusual case of AEN on the setting of chronic alcohol use.
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Affiliation(s)
- Smit S Deliwala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Harini Lakshman
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Douglas D Congdon
- Department of Pathology, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Mamoon M Elbedawi
- Division of Gastroenterology, Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Grigoriy E Gurvits
- Division of Gastroenterology, Department of Internal Medicine, New York University School of Medicine/Langone Medical Center, New York, New York, USA
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3
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Acute Esophageal Necrosis in a Patient With Prostate Cancer Postchemotherapy. ACG Case Rep J 2020; 7:e00366. [PMID: 32548194 PMCID: PMC7224703 DOI: 10.14309/crj.0000000000000366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/12/2020] [Indexed: 11/17/2022] Open
Abstract
Acute esophageal necrosis (AEN) describes a potentially irreversible injury to esophageal mucosa secondary to vascular hypoperfusion. An 84-year-old man was admitted for the correction of a displaced nephrostomy tube and management of acute kidney injury. During his stay, the patient developed odynophagia and acute gastrointestinal hemorrhage. Despite mild initial symptoms, diffuse circumferential black esophageal mucosa was visualized on endoscopy, and a diagnosis of AEN was made. This unique case highlights the association between AEN and leukopenia, vascular disease, hypercoagulability, and infection. Presentations such as this patient should prompt the physicians' consideration of this differential earlier.
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4
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Schizas D, Theochari NA, Mylonas KS, Kanavidis P, Spartalis E, Triantafyllou S, Economopoulos KP, Theodorou D, Liakakos T. Acute esophageal necrosis: A systematic review and pooled analysis. World J Gastrointest Surg 2020; 12:104-115. [PMID: 32218893 PMCID: PMC7061242 DOI: 10.4240/wjgs.v12.i3.104] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 12/02/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute esophageal necrosis (AEN) is a rare entity with multifactorial etiology, usually presenting with signs of upper gastrointestinal bleeding.
AIM To systematically review all available data on demographics, clinical features, outcomes and management of this medical condition.
METHODS A systematic literature search was performed with respect to the PRISMA statement (end-of-search date: October 24, 2018). Data on the study design, interventions, participants and outcomes were extracted by two independent reviewers.
RESULTS Seventy-nine studies were included in this review. Overall, 114 patients with AEN were identified, of whom 83 were males and 31 females. Mean patient age was 62.1 ± 16.1. The most common presenting symptoms were melena, hematemesis or other manifestations of gastric bleeding (85%). The lower esophagus was most commonly involved (92.9%). The most widely implemented treatment modality was conservative treatment (75.4%), while surgical or endoscopic intervention was required in 24.6% of the cases. Mean overall follow-up was 66.2 ± 101.8 d. Overall 29.9% of patients died either during the initial hospital stay or during the follow-up period. Gastrointestinal symptoms on presentation [Odds ratio 3.50 (1.09-11.30), P = 0.03] and need for surgical or endoscopic treatment [surgical: Odds ratio 1.25 (1.03-1.51), P = 0.02; endoscopic: Odds ratio 1.4 (1.17-1.66), P < 0.01] were associated with increased odds of complications. A sub-analysis separating early versus late cases (after 2006) revealed a significantly increased frequency of surgical or endoscopic intervention (9.7 % vs 30.1% respectively, P = 0.04)
CONCLUSION AEN is a rare condition with controversial pathogenesis and unclear optimal management. Although the frequency of surgical and endoscopic intervention has increased in recent years, outcomes have remained the same. Therefore, further research work is needed to better understand how to best treat this potentially lethal disease.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
| | - Nikoletta A Theochari
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Prodromos Kanavidis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Stamatina Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens 11527, Greece
| | - Konstantinos P Economopoulos
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
- Department of Surgery, Duke University Medical Center, Durham, NC 27708, United States
| | - Dimitrios Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens 11527, Greece
| | - Theodore Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
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5
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Dias E, Santos-Antunes J, Macedo G. Diagnosis and management of acute esophageal necrosis. Ann Gastroenterol 2019; 32:529-540. [PMID: 31700229 PMCID: PMC6826069 DOI: 10.20524/aog.2019.0418] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/26/2019] [Indexed: 02/06/2023] Open
Abstract
Acute esophageal necrosis is a rare syndrome classically characterized by a striking endoscopic image of diffuse and circumferential black mucosal discoloration of distal esophagus, with an abrupt transition at the gastroesophageal junction and variable proximal extension. The typical patient is an older male with general debilitation and multiple comorbidities presenting with hematemesis or melena. The pathophysiology usually involves a combination of esophageal ischemia, backflow injury from gastric chemical contents and impaired mucosal reparative mechanisms associated with debilitated physical states. It may arise in the setting of hemodynamic compromise, diabetic ketoacidosis, hypothermia, alcoholic intoxication, trauma, inflammatory diseases, esophageal local infection, solid organ transplantation, postoperative status, drugs or acute gastric outlet obstruction, usually in the background of a chronic debilitating process, where the concurrent presence of multiple risk factors, including diabetes mellitus, hypertension, malnutrition, malignancy or alcohol abuse, places a patient at higher risk. The characteristic endoscopic appearance establishes the diagnosis. Biopsy is supportive but not required. Management is mainly supportive and consists of correcting coexisting conditions, fluid therapy, bowel rest, intravenous proton pump inhibitor therapy and red blood cell transfusion as needed. Although this is a serious life-threatening condition, appropriate treatment may result in a favorable outcome in the majority of patients.
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Affiliation(s)
- Emanuel Dias
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
| | - João Santos-Antunes
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
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6
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Abdullah HM, Ullah W, Abdallah M, Khan U, Hurairah A, Atiq M. Clinical presentations, management, and outcomes of acute esophageal necrosis: a systemic review. Expert Rev Gastroenterol Hepatol 2019; 13:507-514. [PMID: 30933549 DOI: 10.1080/17474124.2019.1601555] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND To review all the reported literature on acute esophageal necrosis. RESEARCH METHODS Databases were searched using the special Medical Subject Heading (MeSH) terms. All the available reported cases of acute esophageal necrosis were analyzed. RESULTS A total of 154 cases were identified and 130 cases were analyzed. The mean age of presentation was 61 years, and 70% of cases were males. The most common presenting symptoms were hematemesis in 66%, shock in 36%, melena in 33%, abdominal or substernal pain in 28%. The most common comorbidities reported were diabetes in 38%, hypertension in 37%, alcohol abuse in 25%, and chronic kidney disease in 16%. On upper endoscopy, 51% had a distal disease, 36% had pan esophageal, and only 2% had a proximal disease. 84% of patients were treated with IV Proton Pump Inhibitors, 22% received transfusions, 23% got antibiotics for underlying sepsis, 14% also received sucralfate, and 4% required surgery for treatment. The mortality rate was 32%, while perforation was reported in 5% and stricture formation reported in 9% of patients. CONCLUSIONS Patients with acute esophageal necrosis can have a favorable outcome if treated appropriately.
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Affiliation(s)
| | - Waqas Ullah
- b Abington Hospital - Jefferson Health , Abington , PA , USA
| | - Mohamed Abdallah
- a Sanford School of Medicine , University of South Dakota , Sioux Falls , SD , USA
| | - Uzma Khan
- c Khyber Teaching Hospital , Peshawar , Pakistan
| | | | - Muslim Atiq
- a Sanford School of Medicine , University of South Dakota , Sioux Falls , SD , USA
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7
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Ullah W, Mehmood A, Micaily I, Khan MS. Comprehensive review of acute oesophageal necrosis. BMJ Case Rep 2019; 12:e227967. [PMID: 30814100 PMCID: PMC6398709 DOI: 10.1136/bcr-2018-227967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2019] [Indexed: 10/27/2022] Open
Abstract
Acute oesophageal necrosis, also known as 'black oesophagus', is a rare condition characterised by the black discolouration of the oesophageal mucosa on endoscopy and involves the distal oesophagus in majority of cases but may also extend proximally. A number of conditions are found to be associated with it and it is thought to occur due to a combination of hypovolaemia and inadequate oesophageal protective mucosal barrier function. Gastric secretions may have a direct effect on the oesophageal mucosa. We present a case of a woman who presented with haematemesis and significant hypotension after a session of haemodialysis. Black oesophagus was confirmed on esophagogastroduodenoscopy. She was given two units of packed red blood cells and one unit of platelets, and started on a pantoprazole infusion. However, despite rigorous attempts at resuscitation the patient failed to recover.
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Affiliation(s)
- Waqas Ullah
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | - Asif Mehmood
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | - Ida Micaily
- Department of Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | - Muhammad Saeed Khan
- Department of Medicine, THQ Hospital Talash, Lower Dir, Khyber Pakhtunkhwa, Pakistan
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8
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Khan H, Ahmed M, Daoud M, Philipose J, Ahmed S, Deeb L. Acute Esophageal Necrosis: A View in the Dark. Case Rep Gastroenterol 2019; 13:25-31. [PMID: 31182940 PMCID: PMC6547274 DOI: 10.1159/000496385] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/19/2018] [Indexed: 11/30/2022] Open
Abstract
Acute esophageal necrosis (AEN), also known as Gurvits syndrome, black esophagus, or acute necrotizing esophagitis, is a rare clinical entity and an unusual reason for upper gastrointestinal bleeding. It is typically described in critically ill patients with multiple medical conditions, arising from a combination of ischemic insult to the esophageal mucosa due to low-flow vascular states, corrosive injury caused by reflux of acid and pepsin, and decreased function of the mucosal barrier systems and reparative mechanisms as occurs in malnourished and debilitated physical states. Patients with AEN tend to be older men, as medical comorbidities including vascular disease, diabetes, hypertension, renal insufficiency, cardiac disease, pulmonary disease, stroke, and cirrhosis may be more common. Typically, patients present with upper gastrointestinal bleeding, and hematemesis or melena is seen in up to 90% of cases. Herein we present 3 cases of AEN in critically ill patients. We also provide a review of the literature to highlight what is currently known about this relatively uncommon esophageal disease.
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Affiliation(s)
- Hafiz Khan
- Department of Gastroenterology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Moiz Ahmed
- Department of Gastroenterology, Mount Sinai School of Medicine, Elmhurst Hospital Center, Elmhurst, New York, USA
| | - Magda Daoud
- Department of Gastroenterology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Jobin Philipose
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Saba Ahmed
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Liliane Deeb
- Department of Gastroenterology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
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9
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Gómez V, Propst JA, Francis DL, Canabal JM, Franco PM. Black esophagus: an unexpected complication in an orthotopic liver transplant patient with hemorrhagic shock. Dig Dis Sci 2014; 59:2597-9. [PMID: 24801686 DOI: 10.1007/s10620-014-3176-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/16/2014] [Indexed: 01/27/2023]
Affiliation(s)
- Victoria Gómez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Davis Building 6, 4500 San Pablo Road, Jacksonville, FL, 32224, USA,
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10
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Barrientos Delgado A, Martínez Tirado MP, Martín-Lagos Maldonado A, Palacios Pérez Á, Casado Caballero FJ. [Extensive esophageal stenosis secondary to acute necrotizing esophagitis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 38:327-9. [PMID: 25150722 DOI: 10.1016/j.gastrohep.2014.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 06/23/2014] [Accepted: 06/29/2014] [Indexed: 10/24/2022]
Affiliation(s)
| | | | | | - Ángel Palacios Pérez
- Unidad Clínica de Aparato Digestivo, Hospital Universitario San Cecilio, Granada, España
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Acute Esophageal Necrosis: A Case of Black Esophagus Associated with Bismuth Subsalicylate Ingestion. ACG Case Rep J 2014; 1:131-3. [PMID: 26157851 PMCID: PMC4435298 DOI: 10.14309/crj.2014.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 02/20/2014] [Indexed: 01/27/2023] Open
Abstract
We present a case of acute esophageal necrosis (AEN) likely caused by chronic use of bismuth subsalicylate, an active ingredient in over-the-counter Pepto-Bismol®, which contains 220 g of salicylic acid in each 30 mL quantity. While aspirin is known to cause gastritis and gastric ulcers, this is the first case, to our knowledge, reporting AEN after chronic bismuth subsalicylate use.
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12
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13
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Acute Esophageal Necrosis: A Case of Black Esophagus Associated with Bismuth Subsalicylate Ingestion. ACG Case Rep J 2014. [DOI: 10.14309/02075970-201401000-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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14
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Forster R, Durso DA, Vattimo EFDQ, Maruta LM, Werneck-Silva AL, Takayasu V, Kanegae MY, Lima FR. Black esophagus: exploring the dark. AUTOPSY AND CASE REPORTS 2013; 3:41-48. [PMID: 31528617 PMCID: PMC6671888 DOI: 10.4322/acr.2013.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 09/10/2013] [Indexed: 12/25/2022] Open
Abstract
Black esophagus is a rare but underdiagnosed disease. It occurs most frequently in severely ill patients and carries a high mortality rate. Cause of death is usually attributed to the comorbid conditions. Treatment is directed at the underlying cause, acid suppression and keeping the patient nil-per-os. Surgery is needed in complicated cases and stenosis is the most feared longterm sequel. In the present article, two cases are described and literature is reviewed.
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Affiliation(s)
- Robert Forster
- Department of Internal Medicine - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Délcio Aparecido Durso
- Department of Internal Medicine - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | | | - Luis Massuo Maruta
- Endoscopy Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Ana Luiza Werneck-Silva
- Endoscopy Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Vilma Takayasu
- Department of Internal Medicine - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Marcia Yoshie Kanegae
- Department of Internal Medicine - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Fabiana Roberto Lima
- Anatomic Pathology Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
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15
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Groenveld RL, Bijlsma A, Steenvoorde P, Ozdemir A. A black perforated esophagus treated with surgery: Report of a case. World J Gastrointest Surg 2013; 5:199-201. [PMID: 23805365 PMCID: PMC3692957 DOI: 10.4240/wjgs.v5.i6.199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 04/02/2013] [Accepted: 05/10/2013] [Indexed: 02/06/2023] Open
Abstract
A case of a perforated black esophagus treated with minimal invasive surgery is presented. A 68-year-old women underwent a right-sided hemihepatectomy and radio frequency ablation of two metastasis in the left liver lobe. Previous history revealed a hemicolectomy for an obstructive colon carcinoma with post-operative chemotherapy. Postoperatively she developed severe dyspnea due to a perforation of the esophagus with leakage to the pleural space. Video-assisted thoracoscopic surgery (VATS) to adequately drain the perforation was performed. Gastroscopy revealed a perforated black esophagus. The black esophagus, acute esophageal necrosis or Gurvits syndrome is a rare entity with an unknown aetiology which is likely to be multifactorial. The estimated mortality rate is high. To our knowledge, this is the first case published of early VATS used in a case of perforated black esophagus.
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16
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Remes-Troche JM. A 'black stomach' due to ingestion of anhydrous calcium chloride. BMJ Case Rep 2013; 2013:bcr-2012-007716. [PMID: 23283618 DOI: 10.1136/bcr-2012-007716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jose Maria Remes-Troche
- Labortorio de Fisiologia DIgestiva y Motilidad, Instituto de Investigaciones Medico Biologicas, Veracruz, Mexico.
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17
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Abstract
Esophageal infarction or acute necrotizing esophagitis is a rare condition that has a dramatic endoscopic appearance of a "black esophagus." The esophageal involvement can vary from the distal third to the total esophagus. Excluding corrosive injury and other well-known rare causes of black esophagus, the etiology of this condition is unknown. Ischemia due to hypoperfusion state is thought to play a central role in the pathogenesis. The treatment is supportive with acid suppression and gastrointestinal rest. Mortality is high due to comorbid conditions.
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Affiliation(s)
- Rami Hawari
- Pankaj J. Pasricha, MD University of Texas Medical Branch, Division of Gastroenterology, Internal Medicine Department, 301 University Boulevard, Galveston, TX 77555, USA.
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18
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Abstract
Acute esophageal necrosis (AEN), commonly referred to as “black esophagus”, is a rare clinical entity arising from a combination of ischemic insult seen in hemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophago-gastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. AEN may arise in the setting of multiorgan dysfunction, hypoperfusion, vasculopathy, sepsis, diabetic ketoacidosis, alcohol intoxication, gastric volvulus, traumatic transection of the thoracic aorta, thromboembolic phenomena, and malignancy. Clinical presentation is remarkable for upper gastrointestinal bleeding. Notable symptoms may include epigastric/abdominal pain, vomiting, dysphagia, fever, nausea, and syncope. Associated laboratory findings may reflect anemia and leukocytosis. The hallmark of this syndrome is the development of diffuse circumferential black mucosal discoloration in the distal esophagus that may extend proximally to involve variable length of the organ. Classic “black esophagus” abruptly stops at the gastroesophageal junction. Biopsy is recommended but not required for the diagnosis. Histologically, necrotic debris, absence of viable squamous epithelium, and necrosis of esophageal mucosa, with possible involvement of submucosa and muscularis propria, are present. Classification of the disease spectrum is best described by a staging system. Treatment is directed at correcting coexisting clinical conditions, restoring hemodynamic stability, nil-per-os restriction, supportive red blood cell transfusion, and intravenous acid suppression with proton pump inhibitors. Complications include perforation with mediastinal infection/abscess, esophageal stricture and stenosis, superinfection, and death. A high mortality of 32% seen in the setting of AEN syndrome is usually related to the underlying medical co-morbidities and diseases.
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19
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Day A, Sayegh M. Acute oesophageal necrosis: a case report and review of the literature. Int J Surg 2009; 8:6-14. [PMID: 19800431 DOI: 10.1016/j.ijsu.2009.09.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 09/24/2009] [Accepted: 09/27/2009] [Indexed: 01/28/2023]
Abstract
AIMS We discuss a case of acute oesophageal necrosis and undertook a literature review of this rare diagnosis. METHODS The literature review was performed using Medline and relevant references from the published literature. RESULTS One hundred and twelve cases were identified on reviewing the literature with upper gastrointestinal bleeding being the commonest presenting feature. The majority of cases were male and the mean age of presentation is 68.4 years. This review of the literature shows a mortality rate of 38%. CONCLUSION Acute necrotizing oesophagitis is a serious clinical condition and is more common than previously thought. It should be suspected in those with upper GI bleed and particularly the elderly with comorbid illness. Early diagnosis with endoscopy and active management will lead towards an improvement in patient outcome.
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Affiliation(s)
- Andrew Day
- Worthing and Southlands Hospitals NHS Trust, Worthing Hospital, Lyndhurst Road, Worthing BN11 2DH, UK.
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20
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Gurvits GE, Shapsis A, Lau N, Gualtieri N, Robilotti JG. Acute esophageal necrosis: a rare syndrome. J Gastroenterol 2007; 42:29-38. [PMID: 17322991 DOI: 10.1007/s00535-006-1974-z] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Accepted: 10/31/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute esophageal necrosis, which presents as a black esophagus on endoscopy, is a rare disorder that is poorly described in the medical literature. In this study, we analyze all cases reported to date to define risk factors, clinical presentation, endoscopic features, histologic appearance, treatment, complications, outcome and etiopathogenesis of the disease and to describe a distinct medical syndrome and propose a staging system. METHODS We searched Medline and PubMed from January 1965 to February 2006 for English-language articles using the key words "acute esophageal necrosis," "necrotizing esophagitis," and "black esophagus." RESULTS A total of 88 patients were reported in the literature during the 40 years, 70 men and 16 women with an average age of 67 years. Patients were generally admitted for gastrointestinal bleeding and cardiovascular event/shock. Patients presented with hematemesis and melena in more than 70% of the cases. Upper endoscopy showed black, diffusely necrotic esophageal mucosa predominantly affecting the distal third of the organ. Necrosis was confirmed histologically in most cases. Complications included strictures or stenoses, mediastinitis/abscesses, and perforations. Overall mortality was 31.8%. CONCLUSIONS This study provides a structured approach to identifying risk factors, diagnosis, and pathogenesis of the acute esophageal necrosis. Risk factors include age, male sex, cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol ingestion, malnutrition, diabetes, renal insufficiency, hypoxemia, hypercoagulable state, and trauma. Mechanism of damage is usually multifactorial secondary to ischemic compromise, acute gastric outlet obstruction, and malnutrition. Overall, acute esophageal necrosis should be viewed as a poor prognostic factor, associated with high mortality from the underlying clinical disease.
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Affiliation(s)
- Grigoriy E Gurvits
- Department of Gastroenterology, St. Vincent's Medical Center, New York Medical College, 153 West 11th Street, NR 11, New York, NY10011, USA
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