Black esophagus: Acute esophageal necrosis syndrome

The Esophageal Mucosa: Clues to Underlying Pathology

Esophageal mucosal abnormalities, when accurately recognized, can provide clues to underlying pathology. In this article, we discuss strategies to enhance the detection and assessment of benign esophageal diseases during upper endoscopy by esophagogastroduodenoscopy (EGD). We provide a summary of skills required to perform high-quality EGD procedures from a technical standpoint, as well as a comprehensive description of the endoscopic appearance of the esophagus in health and in benign, organic diseases including eosinophilic esophagitis (EoE), lymphocytic esophagitis and EoE variants, erosive reflux disease, medication-induced esophageal injuries, infectious esophagitis, and other acute and chronic esophageal injuries. Endoscopic classification systems are also described.

Acute Esophageal Necrosis Associated with Alcoholic Ketoacidosis A Case Report

Acute esophageal necrosis (AEN) is a rare condition associated with ischemia of the esophagus, corrosive injury by gastric fluids and reduced mucosal defense. It is also referred to as "Black Esophagus" or "Gurvit's syndrome". Its clinical presentation is most notable for upper gastrointestinal bleeding with signs and symptoms such as abdominal or epigastric pain, nausea, vomiting, dysphagia and fever. AEN is diagnosed via esophagogastroduodenoscopy, where the cardinal finding is a circumferential black discoloration of the esophagus, usually most pronounced in the distal esophagus. The lesion usually stops abruptly at the gastroesophageal junction. AEN is usually seen in older men with multiple comorbidities (eg, cardiovascular disease, diabetes mellitus) and follows a triggering event (eg, sepsis, diabetic ketoacidosis). We describe the case of a 28-year-old man presenting with acute esophageal necrosis associated with alcoholic ketoacidosis after excessive alcohol consumption, prolonged starvation and self-reported increased intake of venlafaxine and quetiapine.

Black Esophagus Under the Scope: Gurvits Syndrome in a Patient With Diabetic Ketoacidosis

A 60-year-old woman with a history of uncontrolled type 2 diabetes mellitus (DM), hypertension, and coronary artery disease was admitted to the intensive care unit due to diabetic ketoacidosis (DKA) triggered by urosepsis. During her stay, she developed upper gastrointestinal bleeding, manifesting as melena. Esophagogastroduodenoscopy revealed circumferential necrosis of the mid-to-distal esophagus, consistent with acute esophageal necrosis (AEN). The patient received supportive treatment, including proton pump inhibitor therapy and sucralfate. A follow-up gastroscopy four weeks later showed a resolution of necrosis but persistent mild esophagitis. This case highlights AEN as a rare complication in patients with uncontrolled type 2 DM and DKA.

Acute Esophageal Necrosis (Gurvits Syndrome): A Rare Cause of Upper Gastrointestinal Bleeding in Somalia

Acute esophageal necrosis, also known as Gurvits syndrome, is a rare condition due to ischemic compromise and thromboembolic injury to esophagus associated with high mortality. Endoscopically, it is characterized by the circumferential black discoloration of the esophagus. We present the case of a 55-year-old male with a history of multiple comorbidities, including uncontrolled type 2 diabetes mellitus, hypertension, smoker, peripheral arterial disease, and a right above-ankle amputation, who presented with active hematemesis and melena with hemodynamic instability. An esophagogastroduodenoscopy revealed diffuse, circumferential necrotizing esophagitis with black discoloration and ulcerations affecting the middle and distal thirds of the esophagus. The severity increased from the proximal to the distal esophagus, abruptly ending at the gastroesophageal junction. These endoscopic findings, combined with the patient's medical history, were consistent with a diagnosis of acute esophageal necrosis. The patient was admitted to the ward and managed conservatively with intravenous fluid resuscitation, IV proton pump inhibitor twice daily, sucralfate 1 gram every six hours, strict glycemic control using insulin, total parenteral nutrition, empirical IV antibiotics, and placed on nil-per-oral (NPO) for three days. A follow-up esophagogastroduodenoscopy conducted twenty-two days post-admission showed complete healing of the esophageal mucosa without stricture formation. Despite its rarity, prompt diagnosis and management of acute esophageal necrosis are crucial due to its association with high morbidity and mortality, as well as the need to minimize complications such as perforations and strictures, particularly in patients with comorbidities. This case report aims to raise awareness among clinicians in Somalia of this condition as a differential diagnosis in upper gastrointestinal bleeding and to highlight the importance of timely intervention to prevent adverse outcomes.

Prominent black esophagus, Wischnewsky spots, and black duodenum in a fatal hypothermia case with an underlying diabetic ketoacidosis

Hypothermia can occur in patients with diabetic ketoacidosis (DKA), and these two conditions can exacerbate each other. Fatal hypothermia and DKA have overlapping features and findings such as Wischnewsky spots (WS), black esophagus, basal subnuclear vacuolization in the renal tubule, dehydration, and increased acetone levels. Therefore, it may be challenging to differentiate or clarify the context of these two conditions. Herein, we report a case of a 49-year-old man with type 1 diabetes who was found lying in his house in mid-winter. He experienced cardiopulmonary arrest 10 h after the initial discovery and died at the hospital. On autopsy, florid left cardiac blood was observed. Black discoloration of the distal part of the esophageal mucosa, widespread WS in the gastric mucosa, and black discoloration of the duodenal mucosa were observed. Histologically, neutrophil infiltration in the esophageal mucosa, neutrophil infiltration and bleeding in the gastric mucosa, basal subnuclear vacuolization and Armanni-Ebstein lesion in the renal tubule epithelium in the kidney, and hyalinization of the islets of Langerhans were observed in the pancreas. Blood acetone and β-hydroxybutyrate levels were 538 µg/mL and 8947 µmol/L, respectively. Glycated hemoglobin A1c and glucose levels were 16.2% and 883 mg/dL, respectively, while C-reactive protein level was 3.64 mg/dL. In conclusion, obnubilation due to DKA was assumed to be the underlying cause of hypothermia, and the combination of these two conditions led to the outcome of death. The concurrent presence of these conditions likely contributed to the conspicuous mucosal findings in the upper gastrointestinal tract.

Acute Esophageal Necrosis (Black Esophagus) in the Setting of Cardiac Arrhythmia: A Case Report

Acute esophageal necrosis is a rare (0.01%) and life-threatening condition (5% specific-mortality) involving blackening of the esophagus mucosa resulting from a combination of ischemic damage and gastric acid reflux, although the exact pathophysiology is still unclear. A 70-year-old female patient was admitted to the intensive care unit following two episodes of hematemesis. Her medical history included diabetes mellitus and ischemic heart disease. At admission an inaugural complete atrial fibrillation was discovered on electrocardiogram. Biological and bacteriological tests revealed urinary tract infection. An esophageo-gastro-duodenoscopy showed typical blackening of the lower third of the esophagus. Treatment consisted of intravenous fluids, high-dose proton pump inhibitors, nothing through the mouth status and intravenous antibiotic therapy. Repeat esophageo-gastro-duodenoscopy showed significant improvement. However, her condition deteriorated as she succumbed to septic shock. Our patient presented with negative prognostic factors like advanced age, diabetes mellitus, ischemic heart disease and inaugural arrhythmia that may have contributed to the development of acute esophageal necrosis.

Acute Esophageal Necrosis: A Successfully Managed Case

Acute esophageal necrosis is a rare condition associated with a poor prognosis. It typically presents with upper gastrointestinal bleeding, and diagnosis is established via upper gastrointestinal endoscopy. Its etiology is often multifactorial and recommendations regarding its management and treatment are scarce and of low evidence level. We present the case of an 80-year-old male with multiple medical comorbidities, who presented to the Emergency Department with upper gastrointestinal bleeding associated with sepsis of an unknown origin. Upper gastrointestinal endoscopy revealed a necrotic and ulcerated esophagus in almost its entire extension, sparing only the proximal esophagus, which is consistent with stage I acute esophageal necrosis. He was managed with supportive care and discharged home in a stable condition. This report shows that early recognition and subsequent resuscitation are the keystones of management, regardless of diagnostic uncertainty.

Comprehensive study of various vitamin concentrations in the human postmortem blood with an autopsy case report of beriberi

Using human cardiac blood from forensic autopsy cases, comprehensive measurements of albumin, vitamins A, B1, B6, B12, C, D, folate, and PIVKA-Ⅱ were performed. Of 128 cases, 83 were male, with an average age of 61.8 years and average postmortem interval of 44 h. The average concentrations of vitamins were 29.8 μg/dL for vitamin A, 32.2 μg/dL for vitamin B1, 278 ng/mL for vitamin B6 (pyridoxamine), 152 ng/mL for vitamin B6 (pyridoxal), 57.2 ng/mL for vitamin B6 (pyridoxal), 17.9 ng/mL for folate, 1188 pg/mL for vitamin B12, 23.5 μg/mL for vitamin C, 15.0 ng/mL for vitamin D, and 1.03 μg/mL for PIVKA-Ⅱ. An autopsy case of a Japanese middle-aged male with beriberi was also presented, where severe edema and effusion of the cavity and a high NT-proBNP serum value were observed; however, cardiac pathology showed no specific abnormal features. In the present case, the blood vitamin B1 concentration was within the standard clinical range. This study revealed that bloodborne water-soluble vitamin levels shows higher to clinical standard value at postmortem, whereas fat-soluble vitamin levels may stay in the standard range or lower. Our findings suggest that postmortem water-soluble vitamin concentrations within the clinical standard may reflect low antemortem vitamin concentrations.

Markers of Prognosis for Acute Esophageal Necrosis: A Systematic Review

INTRODUCTION

Acute esophageal necrosis (AEN) is a rare and lethal condition that may progress to sepsis and perforations. Most related literature comes from case reports; however, a few small reviews have been published. We conducted a large systematic review of AEN using PubMed, Medline, and Embase to organize data into one consolidated manuscript, find potential prognosticators of illness, and determine possible treatment guidelines for AEN.

METHODS

Advanced searches were performed of all English case reports from 1990 to 2021 using medical subject heading terms. Data on patient age, sex, comorbidities, initial presentation, management, progression of illness, and hospital survival were collected.

RESULTS

Our study included 226 articles, encompassing 319 cases. A total of 32.3% of patients had diabetes, 26.6% had hypertension, and 19.7% had alcohol use disorder. Overall, 66.5% presented with an upper gastrointestinal bleed and 21.9% developed sepsis or esophageal perforation. In total, 60.9% of patients were reported to have survived their illness, but 16.6% of cases did not have their discharge status documented. Interestingly, patients presenting with pain or ketoacidosis demonstrated improved survival.

CONCLUSION

AEN becomes more prevalent as patients age and develop cardiovascular disease, which increases the risk of developing a hypoperfusive state and mucosal injury to the distal esophagus. Early fluid resuscitation, acid-reducing agents, and bowel rest may serve as potential lifesaving interventions, and antibiotics should be considered if there is concern for infection. Patients require close follow-up in anticipation of impending stricture.

INTRODUCTION

Acute esophageal necrosis (AEN) is a rare and lethal condition that may progress to sepsis and perforations. Most related literature comes from case reports; however, a few small reviews have been published. We conducted a large systematic review of AEN using PubMed, Medline, and Embase to organize data into one consolidated manuscript, find potential prognosticators of illness, and determine possible treatment guidelines for AEN.

METHODS

Advanced searches were performed of all English case reports from 1990 to 2021 using medical subject heading terms. Data on patient age, sex, comorbidities, initial presentation, management, progression of illness, and hospital survival were collected.

RESULTS

Our study included 226 articles, encompassing 319 cases. A total of 32.3% of patients had diabetes, 26.6% had hypertension, and 19.7% had alcohol use disorder. Overall, 66.5% presented with an upper gastrointestinal bleed and 21.9% developed sepsis or esophageal perforation. In total, 60.9% of patients were reported to have survived their illness, but 16.6% of cases did not have their discharge status documented. Interestingly, patients presenting with pain or ketoacidosis demonstrated improved survival.

CONCLUSION

AEN becomes more prevalent as patients age and develop cardiovascular disease, which increases the risk of developing a hypoperfusive state and mucosal injury to the distal esophagus. Early fluid resuscitation, acid-reducing agents, and bowel rest may serve as potential lifesaving interventions, and antibiotics should be considered if there is concern for infection. Patients require close follow-up in anticipation of impending stricture.

Severe Diabetic Ketoacidosis in Children with Type 1 Diabetes: Ongoing Challenges in Care

Diabetic ketoacidosis is the most common acute complication in children and adolescents with type 1 diabetes, and contributes significantly to morbidity, mortality, and healthcare burden. This review aims to explore the multifaceted aspects of severe diabetic ketoacidosis in pediatric age, including its epidemiology, pathogenesis, risk factors, complications and emphasizing advances in prevention strategies. Incidence rates vary due to influences from geographic, socioeconomic, cultural and demographic factors. Pathogenesis is linked to insulin deficiency and an excess of counter-regulatory hormones, which disrupt glucose, protein, and lipid metabolism, causing hyperglycemia, ketosis, acidosis, dehydration, and electrolyte imbalances. According to the International Society for Pediatric and Adolescent Diabetes guidelines, severe diabetic ketoacidosis is characterized by a pH < 7.1 or bicarbonate < 5 mmol/L. This condition can lead to a wide range of life-threatening complications, including cerebral edema that represents the leading cause of death. Several prevention strategies, including awareness campaigns, early diagnosis of diabetes, regular monitoring and management, effective insulin therapy, education, access to healthcare and technological assistance, may contribute to reduce the risk of severe diabetic ketoacidosis episodes in children and adolescents.

An Unusual Complication of Diverticular Bleed: Dysphagia and Food Impaction from Black Esophagus

Introduction

Acute esophageal necrosis, or black esophagus, is a rare clinical phenomenon typically seen in older men after an acute triggering event. It may present with dysphagia due to stricturing or dysmotility, a complication of severe esophageal inflammation.

Case Presentation

Here we describe a case of a woman with several cardiovascular risk factors who developed black esophagus following diverticular-related hemorrhagic shock and presented with chest pain followed by dysphagia and food impaction likely as a result of mucosal sloughing and altered esophageal motility. The diagnosis was confirmed endoscopically and pathology revealed coagulative necrosis due to ischemia.

Discussion

Acute esophageal necrosis should be suspected in patients with cardiovascular risk factors and hemodynamic compromise and may be confirmed with endoscopy. As dysphagia may complicate this condition, slow advancement of diet while healing is advised.

Black Esophagus: A Life-Threatening Consequence of Hypoperfusion

Acute esophageal necrosis (AEN) is an uncommon endoscopic finding characterized by a patchy or diffuse circumferential black pigmentation of the esophageal mucosa, corresponding to ischemic necrosis. It usually presents with upper gastrointestinal bleeding and is thought to be caused by a systemic low blood flow in patients with predisposing risk factors, like advanced age and cardiovascular comorbidities. After initial hemodynamic stabilization, diagnosis is established by esophagogastroduodenoscopy (EGD) with careful biopsies and histological evaluation. Delayed diagnosis is thought to be the main cause of panesophageal necrosis, perforation, mediastinitis and septic shock. We present a case of AEN triggered by hypoperfusion due to severe perioperative blood loss in a 72-year-old woman with a history of cardiovascular disease. Even though she was stabilized during surgery, she still presented with melena 24 hours after, and endoscopic examination showed ischemic patches consistent with AEN. After administering intravenous fluids, proton pump inhibitors (PPI) and parenteral nutrition, a repeat EGD after 72 hours showed a neat improvement with erosive and ulcerative lesions replacing the black patches and a complete healing after eight weeks of oral PPI therapy. AEN is a rare but highly deadly entity that endoscopists must be aware of, especially in patients with multiple comorbidities and presenting with gastrointestinal bleeding after an episode of hemodynamic instability. Quick management can significantly improve survival.

Acute esophageal necrosis in the post-operative period: a narrative review of presentation, management, and outcomes

Background

Acute esophageal necrosis (AEN) is a rare clinical condition characterized by diffuse, circumferential, black mucosal discoloration of the distal esophagus. The cause is multifactorial, frequently seen as a sequela to a large physiologic stressor such as trauma, multisystem organ failure, or sepsis. Mortality from AEN has previously been documented as high as 32%. Cases of AEN have been described in the post-operative period, however the etiology has not clearly been defined.

Methods

A review of AEN was performed, predominately through case reports and small series. In combination of clinical experience and review, emphasis was placed on identification of shared risk factors, signs and symptoms and efficacious management.

Key Content and Findings

Patients diagnosed with AEN frequently have a documented history of diabetes, hypertension, and chronic kidney disease. Additional risk factors include duodenal and/or gastric ulcer disease, reflux anemia and malignancy. While more common in patients with multiple comorbidities, AEN is seen otherwise healthy post-operative patients. Surgery can act as a trigger for AEN, documented after transplants, oncologic operations, and routine cholecystectomies. The most common presenting symptom was hematemesis. Management focused on early diagnosis with upper endoscopy, supportive care and reversal of underlying stressors can mitigate morbidity and mortality.

Conclusions

AEN is a rare and life-threatening condition that requires early identification and intervention to prevent severe morbidity and mortality. It not only occurs in patients with multiple comorbidities but also in otherwise healthy patients in response to a large stressor, such as surgery.

Acute Esophageal Necrosis in a Patient With Severe Cardiovascular Disease and Arrhythmia

Acute esophageal necrosis is a gastrointestinal syndrome characterized by diffuse, circumferential, black-appearing mucosa of the distal esophagus and involves various lengths. It is a multifactorial condition involving hypoperfusion from a low flow state, large reflux of gastric contents, and a poor mucosal barrier. Complications involve esophageal stenosis or stricture and esophageal perforation. Treatment is often supportive with correction of underlying conditions, aggressive fluid resuscitation, antacid therapy, and restriction of oral intake. We present an unusual case of black esophagus in a patient with significant cardiovascular disease and rhabdomyolysis and discuss its pathogenesis, management, and outcome.

Acute esophageal necrosis following cardiac arrest: A rare and lethal syndrome with diagnostic challenges

INTRODUCTION AND CLINICAL RELEVANCE

Acute esophageal necrosis (AEN) is a condition characterized by the necrosis of the distal portion of the esophageal mucosa. Risk factors predisposing to this condition are associated to compromised vascular perfusion (e.g. diabetes mellitus, chronic kidney disease, advanced age, and hypertension, shock states). Complications of AEN can be severe including UGI stricture, perforation and overall increased mortality. The true incidence of AEN remains uncertain due to potential subclincal presentations and early resolution.

CASE PRESENTATION

The case outlined involves a 66-years-old obese male with history of alcoholism and lymph-edema of the left leg who presented to the emergency department with hematemesis, haemodynamic instability and impaired consciousness. Shortly after initial assessment, the patient went into cardiac arrest with pulse-less electrical activity (PEA). Return of spontaneous circulation (ROSC) was achieved following instigation of ALS protocol, fluid resuscitation and the administration of a total of 5 mg of adrenaline. Following stabilization, a CT scan was performed which reported a moderately enlarged esophagus with a thickened wall, liquid hypodense material within the esophagus and stomach, and liver cirrhosis. The emergent esophagogastroduodenoscopy (EGDS) revealed extensive mucosal findings indicative of diffuse necrosis with initial scarring, which was later diagnosed as AEN. The patient unfortunately deceased in ICU after developing progression of the AEN, post-cardiac arrest syndrome and liver failure.

CLINICAL DISCUSSION

The presented case highlights several crucial clinical issues and management problems related to AEN. To diagnose AEN, EGDS is still the gold-standard since it allows direct inspection of the esophageal mucosal layer. The management of AEN necessitates a multidisciplinary approach that includes aggressive resuscitation, treatment of underlying comorbidities, and supportive care (e.g. proton pump inhibitors). The mortality rate for AEN remains high despite improvements in diagnosis and treatment highlighting the need to recognize this condition early and intervene promptly in the patients affected. Moreover, long-term sequelae like stricture formation of the esophagus and impaired esophageal motility may contribute to morbidity requiring continuos monitoring. Therefore, to optimize outcomes while reducing complications among affected patients, prompt identification associated with appropriate medical measures are essential. More research needs to be done aiming to better understand the pathophysiology of AEN thereby identifying strategies for its prevention or cure.

CONCLUSIONS

AEN is a rare syndrome characterized by upper gastrointestinal bleeding and hypoxic damage of the esophageal mucosa, often associated with ischemia, gastric outlet obstruction, and compromised protective barriers. Treatment involves aggressive resuscitation, proton pump inhibitors, and monitoring for infection or perforation. However, despite intensive efforts, the mortality rate for AEN remains high at 32 %.

A Case of Metastatic Urothelial Carcinoma-Associated Acute Esophageal Necrosis

Acute esophageal necrosis is a rare syndrome with endoscopic findings of a diffuse circumferential pattern of black mucosa. Although underlying pathogenesis is unclear, it is known to have associations with malignancy. We present a rare case of a patient with a history of metastatic urothelial carcinoma who was found to have acute esophageal necrosis.

A rare cause of acute esophageal necrosis: A case report

Acute esophageal necrosis (AEN) or black esophagus is a rare entity characterized by diffuse circumferential black pigmentation of the esophageal mucosa due to ischemic necrosis. It may be lethal, especially among elderly patients with multiple comorbidities and hemodynamic instability. Diagnosis is based on gastroscopy. Treatment consists of intravenous fluids, proton pump inhibitors, and additional therapies to treat the underlying illness. We report a rare case of a woman in her 50s with cervical cancer who presented with hematemesis and sepsis. Upper gastrointestinal endoscopy showed a black esophagus and an ulcerobudding duodenal process. Few days later, she developed abdominal distension with diffuse pain. Abdominal CT scan demonstrated perforation of gastroduodenal tumor. The treatment was based on resuscitation, proton pump inhibitors, antibiotics, and surgery of the perforated tumor. Unfortunately, the patient died 2 days later because of septic shock. The black esophagus is a fatal complication, thus diagnosis at an early stage and timely management may improve survival. This is the first case reported of AEN due to perforated duodenal tumor explained by septic shock leading to an ischemic esophageal injury.

Multidisciplinary Management of a Patient with acute Oesophageal Necrosis and Severe Neurological Symptoms with Full Recovery

Background

Acute oesophageal necrosis is a rare and poorly understood disorder of the oesophagus. It poses significant diagnostic and therapeutic challenges as it often presents with multiple comorbidities and a poor prognosis.

Case report

We report a case of 42-year-old male with no significant medical history, who presented to our clinic due to neurological deficits and repeated vomiting for 2 weeks. He initially denied alcohol abuse. Upper endoscopy demonstrated circular black discoloration of the distal oesophagus. The patient was treated with proton pump inhibitors and received treatment for his comorbidities. Esophagogastroduodenoscopy was performed to assess improvement. The patient's symptoms gradually resolved.

Conclusion

This case is one of the few to show an association between alcohol abuse and acute oesophageal necrosis and underscores the importance of timely diagnosis and multidisciplinary treatment in patient with fully recovered condition.

LEARNING POINTS

Acute oesophageal necrosis (AEN) is rare but serious condition often overlooked in patients with gastrointestinal symptoms, particularly younger patients and those with a history of alcohol abuse.This case illustrates how a single patient can have multiple acute conditions (AEN, pancreatitis, stomach and duodenal ulcers), necessitating a multidisciplinary approach to care.

A Case of Diabetic Ketoacidosis Complicated With Necrotizing Esophagitis

Acute necrotizing esophagitis (ANE) is known as the "black esophagus." We present a case of ANE in a patient with slowly progressive type 1 diabetes mellitus. A 49-year-old man presented with vomiting, characterized by coffee residue-like emesis, and was diagnosed with diabetic ketoacidosis. Upper gastrointestinal endoscopy revealed black mucosa extending from the middle of the esophagus to the gastric junction, leading to a diagnosis of ANE. The patient was treated with proton pump inhibitors and showed marked improvement. The patient was discharged on the 20th day of illness.

Black Esophagus: A Rare Case of Acute Esophageal Necrosis

Acute esophageal necrosis (AEN) also known as necrotizing esophagitis or black esophagus is an extremely rare cause of upper gastrointestinal (GI) bleeding. This condition is considerably rare, and the exact pathophysiology of the development of AEN is still unclear. There is consensus that it is caused by a combination of esophageal mucosal injury due to gastric acid and ischemic injury due to vascular compromise. The management of AEN includes correcting the multitude of underlying predisposing conditions as well as agile symptomatic management and close monitoring for signs of hemodynamic compromise. We here present an interesting case of a middle-aged male patient who presented with hematemesis and underwent emergent esophagogastroduodenoscopy (EGD), which revealed severe necrotic esophagus. We also discussed the risk factors, pathophysiology, and management of AEN.

Successful treatment of esophageal perforation due to black esophagus (acute esophageal necrosis): a case report

BACKGROUND

Black esophagus, or acute esophageal necrosis (AEN), is a rare disease with a poor prognosis in which the esophageal mucosa is black in color. We report a case of esophageal perforation due to AEN that was successfully treated.

CASE PRESENTATION

An 88-year-old woman presented to her local hospital with the chief complaint of abdominal pain. Endoscopic and radiological examinations revealed esophageal perforation due to AEN and duodenal perforation. Omental patch repair was performed for the esophageal perforation, and the duodenal ulcer perforation was treated by simple closure and gastrojejunostomy at the local hospital. Following refractory esophageal and duodenal perforations after the initial surgery, the patient was transferred to our hospital where emergent surgery was performed, comprising thoracoscopic esophagectomy, cervical esophagostomy, T-tube drainage, and omentopexy for duodenal perforation, as well as thoracic and abdominal drainage. Mucosal regeneration of the esophagostomy was confirmed endoscopically on postoperative day 19.

CONCLUSIONS

Appropriate surgical intervention may be an optimal option in patients with esophageal perforation due to AEN.

An Unusual Case of Black Esophagus

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.

Black esophagus

A 76-year-old man with multiple cardiovascular risk factors (hypertension, DM2, LD, smoker) and severe peripheral arterial disease (iliofemoral bypass, supracondylar amputation) came to the emergency with coffee ground emesis and mild anemia. Urgent gastroscopy showed diffuse circumferential black mucosa covered by fibrin affecting the middle and distal esophageal third. Acute esophageal necrosis is a rare cause of gastrointestinal bleeding that should be suspected in patients with cardiovascular risk factors with an image of a black esophagus that is abruptly interrupted at the EGJ.

A rare case of combined black esophagus and stomach: a case report

Background

Black esophagus is a relatively rare phenomenon that seems to occur in a morbid patient population, however, this entity may be more common than we currently know. Additionally, black esophagus may even be reversible in some cases. There are far fewer cases of black stomach described. The exact etiology and cause are less well known but may have similar risk factors as black esophagus. These disease pathologies are devastating to the patients they affect and can pose clinical challenges for the providers that encounter them.

Case Description

This case report details our experience with a moribund patient who was found to have extensive pneumomediastinum and gastric perforation secondary to black esophagus and black stomach. This was diagnosed on endoscopy following imaging that showed extensive pneumomediastinum. Initially the intent was to temporize the disease process in an attempt to stabilize the patient however at the time of diagnosis, the degree of ischemia had led to perforation and the disease process was not reversible or recoverable. He ultimately expired after comfort directed care measures were put in place.

Conclusions

To the best of our knowledge, this case will be the first reported in current literature and will hopefully shed some light on this unusual and devastating pathology.

Acute Esophageal Necrosis and Duodenal Disease in the Setting of Recently Initiated Chemotherapy

Introduction

Acute esophageal necrosis (AEN), commonly referred to as "black esophagus" or Gurvits syndrome, is a rare condition characterized by diffuse black mucosa in the distal esophagus. Most often, the patient is an older male with multiple comorbidities, presenting with upper gastrointestinal bleeding. The exact pathogenesis is unclear, but it is often thought to be secondary to acute vascular hypo-perfusion or ischemia of the esophageal mucosa in critically ill patients with certain secondary comorbid conditions such as renal insufficiency, diabetes mellitus, dyslipidemia, coronary artery disease, malnourishment, alcohol abuse, or association with an underlying malignancy.

Case Presentation

We present a case of AEN in a 78-year-old female following the recent start of a chemotherapy regimen with carboplatin and paclitaxel two weeks prior. The patient underwent EGD and was found to have AEN throughout the entirety of her esophagus with necrosis and eschars seen up to the second part of the duodenum. The patient initially improved after receiving blood transfusions, being made nil-per-os, and starting proton pump inhibitor (PPI) therapy, but she ultimately died given the severity of her clear cell uterine cancer and other comorbidities.

Conclusion

Although it is rare that initiation of chemotherapy leads to AEN, it should be considered as a potential etiology.

Acute Esophageal Necrosis as a Rare Complication of Metabolic Acidosis in a Diabetic Patient: A Case Report

BACKGROUND Acute esophageal necrosis, or Gurvits syndrome, is a rare clinical process often secondary to a systemic low-flow state. It can be caused by several medical conditions, and it is thought to arise from a combination of impaired mucosal barrier and chemical and ischemic insults to the esophagus. Acute esophageal necrosis usually presents with severe complications due to delayed diagnosis and only rarely has surgical indications. We present a case of Gurvits syndrome, presumably triggered by metabolic acidosis in a diabetic patient. CASE REPORT A 61-year-old man with history of hypertension and type 2 diabetes mellitus treated with metformin, canagliflozin, glimepiride, and pioglitazone came to our attention with persistent vomiting, odynophagia, chest pain after each meal, and progressive weight loss. Arterial blood analysis showed mild metabolic acidosis, while the first esophagogastroduodenoscopy performed revealed a circumferential black appearance of the esophageal mucosa, as in concentric necrosis of the distal esophagus with possible fungal superinfection. Brushing cytology confirmed the infection by Candida spp. and the patient was treated with intravenous fluconazole. The second esophagogastroduodenoscopy, performed after 2 weeks, showed almost complete healing of the esophageal mucosa; in this case, biopsy confirmed mucosal ischemia and necrosis, without showing deep impairment of the mucosa by fungal agents. CONCLUSIONS Due to its high lethality, often caused by the underlying medical diseases, acute esophageal disease should be considered in the differential diagnosis of digestive symptoms, even without upper gastrointestinal bleeding. Prompt diagnosis and treatment of contextual collateral conditions can help clinicians to avoid the worst outcomes of the disease. Among the causative factors of metabolic acidosis leading to esophageal necrosis we recognized metformin and dapagliflozin.

Thoracoscopic esophagectomy for stenosis of thoracic esophagus due to acute esophageal necrosis associated with alcoholic ketoacidosis

Acute esophageal necrosis (AEN) is a rare disease characterized by the appearance of diffuse black mucosa on upper gastrointestinal endoscopy; the condition often progresses to esophageal stenosis in the chronic phase. A 70-year-old man was admitted to a neighborhood hospital with the diagnosis of alcoholic ketoacidosis and an upper gastrointestinal endoscopy performed to investigate the symptom of esophageal tightness revealed AEN. The patient developed esophageal stenosis with scarring in the chronic phase and was referred to our hospital for surgery 6 months after the diagnosis of AEN. We performed thoracoscopic esophagectomy with the patient in the prone position. Although the esophagus was thickened and strong adhesions were present around the esophagus due to inflammation, we were able to complete the surgical procedure thoracoscopically. In patients presenting with benign esophageal stenosis developing after AEN, thoracoscopic esophagectomy may be a useful treatment option, even in the presence of severe fibrosis.

Evaluation of Esophageal Dysphagia in Elderly Patients

PURPOSE OF REVIEW

While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence.

RECENT FINDINGS

In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.

A Rare Case of Acute Esophageal Necrosis Precipitated by Klebsiella Pneumoniae

Acute esophageal necrosis is a rare condition; visualization of necrosis on esophagoduodenoscopy can help establish the diagnosis. Due to variations in blood supply, there is a higher propensity for ischemic episodes to occur along the lower esophagus; these can be of particular importance during times of hypotension. Underlying infections and atherosclerosis can further exacerbate blood supply leading to ischemia in these watershed zones. We present a case of a patient with Klebsiella pneumonia who was found to have "coffee-ground" output on nasogastric tube suctioning. Esophagoduodenoscopy was performed, which showed evidence of circumferential esophageal necrosis. Unfortunately, despite antibiotic and vasopressor support, the patient ultimately passed away.

Comprehensive Review: Acute Esophageal Necrosis in the Setting of Gastric Volvulus

BACKGROUND AND AIMS

Acute esophageal necrosis (AEN) in the setting of gastric volvulus is a rare condition with only a handful of cases reported. Volvulus may contribute to AEN by limiting tissue perfusion and promoting massive reflux of gastric contents on compromised esophageal mucosa.

METHODS

We reviewed 225 original articles, literature reviews, case series, brief reports, case reports, and discuss six total cases of co-occurring esophageal necrosis and gastric volvulus.

RESULTS AND CONCLUSIONS

We present the first comprehensive analysis of all reported cases in the literature to date and formulate management strategies for the co-occurrence of AEN and volvulus. Management of AEN should be directed at correcting underlying medical conditions, providing hemodynamic support, initiating nil-per-os restriction, and administering high-dose proton pump inhibitor therapy. Surgical intervention is typically reserved for cases of esophageal perforation with mediastinitis and abscess formation.

Isolated Proximal Black Esophagus in a COVID-19 Patient

Black esophagus or acute esophageal necrosis (AEN) is a rare cause of upper gastrointestinal (UGI) bleeding usually involving distal esophagus. Proximal esophageal involvement is quite rare. We present an 86-year-old female with active coronavirus disease 2019 (COVID-19) infection who came in with newly diagnosed atrial fibrillation and was started on anticoagulation. She subsequently developed a UGI bleed, which was complicated by inpatient cardiac arrest. Following resuscitation and stabilization, UGI endoscopy showed circumferential black discoloration of proximal esophagus, with distal esophageal sparing. Conservative management was instituted and fortunately, repeat UGI endoscopy two weeks later showed improvement. This describes the first case of isolated proximal AEN in a COVID-19 patient.

Use of Indocyanine Green Fluorescence Angiography and Prophylactic Endoscopic Stenting in Esophagectomy for Acute Esophageal Necrosis

Acute esophageal necrosis (AEN) is a rare condition with high mortality. We describe a case of an AEN accompanied with multiple esophageal perforations in a 40-year-old patient. This was addressed via emergency Ivor-Lewis-esophagectomy with intraoperative Indocyanine-Green-Angiography (ICGA) and prophylactic placement of a self-expanding metal-stent (SEMS).

Acute Esophageal Necrosis in Acute Pancreatitis-Report of a Case and Endoscopic and Clinical Perspective

Esophageal stroke, also known as acute esophageal necrosis or Gurvits syndrome, is an entity that has gained more and more recognition in the last two decades. It is also named "black esophagus" because of striking black discoloration of the esophageal mucosa, with an abrupt transition to normal mucosa at the gastroesophageal junction. Its most common clinical presentation is represented by upper gastrointestinal bleeding and esophagogastroduodenoscopy is the main diagnostic tool. Among the etiopathogenetic and multiple predisposing factors described are hypovolemia, shock state, ischemia, congestive heart failure, acute renal failure, infections, trauma, and diabetes mellitus. Current management of this condition consists of treating the underlying pathology, nil per os, and antacid administration in uncomplicated cases. Although most of the cases have favorable prognosis, complications such as pneumomediastinum or esophageal stricture may occur and fatal cases are a consequence of underlying comorbidities.

"Black Esophagus" or Gurvits Syndrome: A Rare Cause of Upper Gastrointestinal Bleeding in Diabetic Ketoacidosis

Black esophagus, also called Gurvits syndrome or acute esophageal necrosis (AEN), is a rare, life-threatening condition characterized by necrosis of the esophageal mucosa. We present a 36-year-old man who presented with hematemesis and was admitted for diabetic ketoacidosis (DKA) management. He then had a further episode of hematemesis with hemodynamic instability. The esophagogastroduodenoscopy (EGD) revealed ulcerative, necrotizing, circumferential esophagitis in the middle and distal third of the esophagus. The patient was treated with intravenous fluid resuscitation, proton pump inhibitors, empiric antibiotics, and antifungals. Hematemesis in DKA should raise suspicion for black esophagus. Prompt detection of AEN allows for early management and thus reduces mortality and associated complications such as perforations and strictures.

Asymptomatic Esophageal Necrosis in a Patient with Recent COVID-19: The First Case Diagnosed through Autopsy

Acute esophageal necrosis is a rare condition, characterized by a distinctive endoscopic/necropsic image-circumferential black area of the esophagus. This paper presents a case of a 78-year-old patient with recent history of a severe form of COVID-19 (2 months previously), with multiple comorbidities, which presents sudden death in hospital. Anatomic-pathological autopsy showed extensive esophageal necrosis, pulmonary thromboses, and coronarian and aortic atherosclerosis. The histopathological examination revealed necrosis of the esophageal mucosa and phlegmonous inflammation extended to the mediastinum, chronic pneumonia with pulmonary fibrosis, viral myocarditis, papillary muscle necrosis, and pericoronary neuritis. Thromboses and necroses were identified also in the liver, pancreas, and adrenal glands. Post-COVID-19 thromboses can manifest late, affecting various vascular territories, including esophageal ones. Their clinical picture may be diminished or absent in elderly and/or diabetic patients.

Acute Esophageal Necrosis or Black Esophagus in the Setting of Diabetic Ketoacidosis

Acute esophageal necrosis (AEN) or black esophagus is a rare cause of mortality in patients with gastrointestinal bleeding. We present a case of a 54-year-old female who presented with diabetic ketoacidosis (DKA) and developed melena eventually attributed to AEN. The esophagogastroduodenoscopy (EGD) identified severe inflammation with black discoloration consistent with acute esophageal necrosis in the middle and lower esophagus. The patient was managed with intravenous pantoprazole and total parenteral nutrition (TPN) until she was able to tolerate an adequate diet. Black esophagus should be added to the differential diagnosis of patients with DKA who develop gastrointestinal bleeding. This need is stressed by the fact that early treatment is essential to reducing complications and mortality associated with the condition.

Acute Esophageal Necrosis: A Retrospective Cohort Study Highlighting the Mayo Clinic Experience

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.

„Black esophagus“ – zwei Obduktionsfälle mit infektiöser Beteiligung

„Black esophagus“ oder „akute Ösophagusnekrose“ (AÖN) ist eine seltene Erkrankung, die sich makroskopisch durch eine zirkumferente Schwarzverfärbung der Ösophagusmukosa mit abruptem Ende am gastroösophagealen Übergang auszeichnet. Die genaue Pathogenese ist unbekannt; es werden multifaktorielle Einflüsse wie z. B. Säurereflux, Ischämie und verringerte Schutzmechanismen der Mukosa als mögliche Ursachen diskutiert.

Vorgestellt werden 2 Obduktionsfälle, die typische Befunde einer AÖN aufwiesen. Zusätzlich hatten Fall 1 eine Candida-Infektion und Fall 2 eine Appendizitis, sodass eine infektiöse Genese in beiden Fällen eine Rolle gespielt haben könnte.

Gastrointestinal Ischemia—Stumbling Stone in COVID-19 Patients

The emergence of the novel SARS-CoV2 virus, proclaimed by the World Health Organization (WHO) as a culpable agent for the pandemic situation, caught the scientific and medical communities off guard. One of the most common complications following pulmonary disease is represented by gastrointestinal (GI) disorders, especially ischemic damage. Inflammation, vasculopathy, immobility, endothelial dysfunction, and a hypercoagulable condition have all been proposed as pathophysiological factors for GI ischemia in these patients. Owing to the COVID-19 effect on a variety of GI conditions, especially ischemic changes, and the high mortality rate, physicians should always keep in mind this complication. They should take a deeper look at clinical and imaging modalities in this cohort of patients so that a proper and time-saving treatment strategy can be applied. Our study aimed to elucidate the thrombogenic mechanism in different GI disorders. Moreover, we analyzed the factors related to necrotic GI changes, by summarizing the already reported data of GI ischemia in COVID-19. To the best of our knowledge, this review is the first to incorporate all GI ischemia cases reported in the literature so far.

Gurvits syndrome: a case of acute esophageal necrosis associated with diabetic ketoacidosis

Background

Acute esophageal necrosis (AEN), commonly referred to as Gurvits syndrome or “black esophagus”, is a rare clinical disease. We present a case of AEN associated with diabetic ketoacidosis (DKA).

Case presentation

A 66-year-old male came to our hospital with coffee-ground emesis, dyspnea, and general malaise. He was treated for type 2 diabetes mellitus using insulin and had not been taking his medication, including insulin, for several days. Laboratory analysis revealed severe hyperglycemia (730 mg/dL), normocytic anemia (hemoglobin level, 7.7 g/dL; mean corpuscular volume, 100.4 fL), high serum potassium (7.6 mEq/L), and a high level of blood urea (98.7 mg/dL). Ketones and glucose were detected in the urine, and serum β-hydroxybutyrate was elevated (2132 µmol/L). Arterial blood gas analysis confirmed metabolic acidosis (pH, 7.29; HCO₃, 10.5 mmol/L). Collectively, the patient was diagnosed with DKA and upper gastrointestinal bleeding. The patient’s condition improved with intravenous fluids, and he received intravenous insulin to treat DKA. According to these findings, the patient was diagnosed with DKA and upper gastrointestinal bleeding. The patient underwent esophagogastroduodenoscopy (EGD) which revealed a circumferential necrosis of the middle and distal esophagus, immediately proximal to the gastroesophageal junction. The patient was then treated with an intravenous proton pump inhibitor. The patient continued to improve with conservative treatment and was subsequently discharged in a stable condition. An EGD repeated 14 days after discharge showed complete healing of the necrotic-like mucosal change without stricture formation of the esophagus.

Conclusions

AEN is rare but potentially life-threatening case of upper gastrointestinal bleeding. Therefore, a clinician should be aware of AEN as a potential cause of upper gastrointestinal bleeding in elderly patients with poorly controlled diabetes and significant comorbidities.

Gurvits syndrome in diabetic ketoacidosis

Gurvits syndrome, black esophagus or acute esophageal necrosis (AEN) is a rare and multifactorial disorder resulting from a combination of ischemic insult, corrosive injury of the mucosa from gastric contents, and impaired reparative mechanism in the setting of acute illness. The diagnosis is made by visualization of a circumferential black discoloration of the distal oesophagus that abruptly ends at the gastroesophageal junction. We report a case of Gurvits syndrome secondary to diabetic ketoacidosis (DKA).

Endoscopic balloon dilation for the prevention of severe strictures caused by acute esophageal necrosis

A 58‐year‐old man who had the history of alcohol dependence was referred to our emergency center due to severe nausea, vomiting, and subsequent onset of chest and back pain. Esophagogastroduodenoscopy (EGD) showed black‐appearing esophagus mucosa extending from the cervical esophagus to the esophagogastric junction with clear margins, a condition typically referred to as a black esophagus. Alcohol abuse was considered an important factor associated with acute esophageal necrosis in this patient. After admission, he received fluid resuscitation and proton‐pump inhibitors, with restriction of oral intake and treatment of alcohol dependence. Follow‐up EGDs and endoscopic balloon dilation were performed for the management of esophageal narrowing before the development of severe strictures. Strictures were successfully treated endoscopically without complications such as perforation.

Unusual case of acute oesophageal necrosis

Acute oesophageal necrosis is a rare clinical entity that commonly affects the distal oesophagus, giving it a characteristic black appearance. It is associated with a high mortality and predominantly impacts critically ill patients. In this case report, we present a male patient in his 50s with multiple comorbidities admitted for management of ketoacidosis. The patient was overall well appearing and remained haemodynamically stable throughout the entirety of his hospital course. Despite this, necrosis was found in the proximal, middle and distal portions of the patient's oesophagus. The presence of such extensive oesophageal injury was very atypical considering the lower severity of the patient's condition.