Acute esophageal necrosis: a rare syndrome

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 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.

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.

Prevalence and clinical features of severe diabetic ketoacidosis treated in pediatric intensive care unit: a 5-year monocentric experience

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the most alarming concerns in the management of type 1 diabetes (T1D) in pediatric age. Prevalence of DKA at the onset of diabetes ranges from 30 to 40%. In selected cases of severe DKA, admission to pediatric intensive care unit (PICU) should be considered.

METHODS

This study aims to assess the prevalence of severe DKA treated in PICU in our 5-year monocentric experience. Secondary outcome of the study was to describe the main demographical and clinical features of individuals who required admission to PICU. All clinical data were collected by retrospectively reviewing the electronic medical records of children and adolescents with diabetes hospitalized in our University Hospital from January 2017 to December 2022.

RESULTS

During the study period, 103 children and adolescents were newly diagnosed with T1D. Among these, 51.5% presented clinical criteria for DKA and almost 10% needed to be treated in PICU. A higher rate of new T1D diagnoses was observed in 2021, as well as episodes of severe DKA being more frequent than in previous years. Due to severe clinical manifestations of DKA, 10 subjects (9.7%) with T1D onset needed to be treated in PICU. Of these, four children were younger than 5. The great majority came from a low household income and some of them had also immigrant background. The most common complication of DKA was acute kidney injury presented by four children. Other complications were cerebral edema, papilledema and acute esophageal necrosis. A 15-year-old girl had deep vein thrombosis (DVT) that evolved into multiple organ failure leading to death.

CONCLUSIONS

Our findings demonstrated that severe DKA is still quite common in children and adolescents at T1D onset, especially in some areas such as Southern Italy. Public awareness campaigns should be increasingly promoted to facilitate the recognition of early symptoms of diabetes and to reduce morbidity and mortality related to DKA.

The Forgotten Complication of Nasogastric Tube Insertion: Esophageal Perforation and Associated Hydropneumothorax and Hydropneumoperitoneum

Nutritional support is essential for critically ill patients to reduce mortality and length of stay. Frequently nasogastric (NG) tubes are used to provide enteral nutrition. A very rare risk of NG tube placement is esophageal perforation, most commonly in the thoracic portion of the esophagus. Here we describe a case of a 41-year-old male with multiple risk factors for esophageal integrity disruption who initially presented for diabetic ketoacidosis (DKA) requiring intubation. Following intubation, an NG tube was placed for nutritional support. The following day the patient developed hydropneumothorax and hydropneumoperitoneum. He was taken emergently for surgical correction of suspected perforation. It was found that the patient had esophageal perforation from the distal esophagus to the proximal portion of the lesser curvature of the stomach. The NG tube transversed the proximal portion of the tear and re-entered at a distal site. The distal portions of the esophagus showed necrotic superficial layers with viable muscularis layers. The patient gradually improved after surgical intervention and was discharged to a long-term acute care facility. It is essential as medical providers to be familiar with complications of NG tube placement and risk factors that could increase the risk of esophageal perforation.

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.

Clinical features of acute esophageal mucosal lesions and reflux esophagitis Los Angeles classification grade D: A retrospective study

BACKGROUND

Acute esophageal mucosal lesions (AEMLs) are an underrecognized and largely unexplored disease. Endoscopic findings are similar, and a higher percentage of AEML could be misdiagnosed as reflux esophagitis Los Angeles classification grade D (RE-D). These diseases could have different pathologies and require different treatments.

AIM

To compare AEML and RE-D to confirm that the two diseases are different from each other and to clarify the clinical features of AEML.

METHODS

We selected emergency endoscopic cases of upper gastrointestinal bleeding with circumferential esophageal mucosal injury and classified them into AEML and RE-D groups according to the mucosal injury’s shape on the oral side. We examined patient background, blood sampling data, comorbidities at onset, endoscopic characteristics, and outcomes in each group.

RESULTS

Among the emergency cases, the AEML and RE-D groups had 105 (3.1%) and 48 (1.4%) cases, respectively. Multiple variables exhibited significantly different results, indicating that these two diseases are distinct. The clinical features of AEML consisted of more comorbidities [risk ratio (RR): 3.10; 95% confidence interval (CI): 1.68–5.71; P < 0.001] and less endoscopic hemostasis compared with RE-D (RR: 0.25; 95%CI: 0.10–0.63; P < 0.001). Mortality during hospitalization was higher in the AEML group (RR: 3.43; 95%CI: 0.82–14.40; P = 0.094), and stenosis developed only in the AEML group.

CONCLUSION

AEML and RE-D were clearly distinct diseases with different clinical features. AEML may be more common than assumed, and the potential for its presence should be taken into account in cases of upper gastrointestinal bleeding with comorbidities.

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.

Analysis of the pathogenesis of acute necrotizing esophagitis (black esophagus): A report of three autopsy cases

Acute necrotizing esophagitis (ANE) is a rare condition characterized by black discoloration of the esophageal mucosa. We describe three autopsy cases of ANE, also known as black esophagus. The black discoloration was confined to the esophageal mucosa rather than to the gastric mucosa. The histological findings of brown pigmentation and acute inflammation led to an ANE diagnosis. The immediate cause of death was certified as ANE in all cases. In the three cases, one had hypertension, diabetes, and multiple cerebral infarctions, another had alcoholism, whereas the pre-existing condition was unknown in the remaining patient. Petechial hemorrhages were found on the gastric mucosa of all three patients as a finding of terminal hypothermia. In one case, frequent vomiting was observed prior to death. Blood alcohol was detected (the patient had been drinking immediately prior to death), and the onset of ANE was considered to have occurred several hours before death. The findings indicate that ANE occurs shortly before death in combination with frequent vomiting and terminal hypothermia in the setting of cerebrovascular disease or alcoholism.

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.

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.

Characteristics, Outcomes, and Risk Factors for Upper Gastrointestinal Bleeding in Inpatients - A Comparison with Outpatients

Objective The study objectives were to clarify the clinical findings and the causes of intractability and mortality of upper gastrointestinal (UGI) bleeding in inpatients. Methods The patients were divided into Inpatient (Ip) and Outpatient (Op) onset groups, and their characteristics, clinical and bleeding data, and outcomes were compared. Patients or Materials Our study included 375 patients who developed UGI bleeding during hospitalization or were admitted after being diagnosed with UGI bleeding in an outpatient setting from January 1, 2015, to June 30, 2020. Results The Ip group had worse general condition; increased percentages of comorbidities; and more common use of proton pump inhibitor, anti-coagulant, and steroid than the Op group. Compared with the Op group, the Ip group had lower serum albumin levels and platelet counts at the onset of bleeding, whereas rebleeding, mortality, and bleeding-related death rates were higher. Multivariate analysis of the Ip group revealed that the risks of rebleeding included endoscopic high-risk stigmata, maintenance dialysis, and duodenal bleeding, whereas the risks of mortality were gastric ulcer and a Charlson Comorbidity Index update score of ≥3. Conclusion UGI bleeding in the Ip group was associated with higher rebleeding and mortality rates. Because of their poor general health condition, the pathology of UGI bleeding in these patients may differ from that of patients with common UGI bleeding. A different approach for the care and prevention of UGI bleeding in inpatients is required.

„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.

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.

Acute Esophageal Necrosis Syndrome (Black Esophagus): A Case Report of Rare Presentation

Acute esophageal necrosis (AEN) is a rare clinical finding due to multifocal factors consisting of an ischemic insult to the esophagus, corrosive injury from gastric content, and diminished mucosal defense. It is also referred to as “black esophagus” or acute necrotizing esophagitis. The clinical presentation mainly consists of upper gastrointestinal bleed and abdominal pain. Associated symptoms include nausea, vomiting, and dysphagia. AEN can be diagnosed by esophagogastroduodenoscopy (EGD) with findings of diffuse circumferential black pigmentation in the distal esophagus that classically extends to the gastroesophageal junction. A diagnostic biopsy is not required but recommended. Treatment of AEN is conservative management to maintain hemodynamic stability and treat coexisting medical conditions. Herein, we present the case of a 78-year-old male who initially presented with hematemesis and abdominal discomfort of five-day duration and was subsequently found to have AEN.

Case Report of Acute Esophageal Necrosis (Gurvits Syndrome) in Vaccinated, COVID-19-Infected Patient

Acute esophageal necrosis (AEN) is a rare endoscopic finding associated with ischemic compromise of the distal esophagus. This finding can be seen in critically ill patients with COVID-19 infection. We present a case of a COVID-19-vaccinated elderly male with multiple comorbidities and active COVID-19 pneumonia admitted to the intensive care unit with septic shock and acute hypoxemic respiratory failure. The patient developed melena, and esophagogastroduodenoscopy (EGD) was performed, which showed necrosis of the lower esophagus suggestive of AEN. AEN has been associated with high mortality and should be considered when evaluating upper gastrointestinal bleed in a critically ill patient. This case describes the first report of isolated AEN in a patient fully vaccinated against COVID-19 presenting with a severe complicated COVID-19 infection.

Risk factors and clinical outcomes of acute esophageal necrosis: retrospective case series of a rare disease with "black" prognosis

Acute esophageal necrosis is a rare syndrome classically characterized by black distal esophagus with a complex pathophysiology that usually involves a combination of esophageal ischemia, gastroesophageal reflux and impaired mucosal reparative mechanisms. We retrospectively analyzed the main risk factors, clinical characteristics and outcome in all patients diagnosed with acute esophageal necrosis between January 2015 and December 2020 at our center. Ten patients were identified in a total of 26854 upper digestive endoscopies (0.04%). Most patients were male (8/10) and the mean age of presentation was 71.1 years. The most common presenting symptoms were melena and hematemesis and half the patients required red blood cell transfusion. The most common risk factors were hypertension, diabetes mellitus, dyslipidemia, chronic kidney disease, peripheral artery disease, coronary artery disease, cerebrovascular disease, heart failure and malignancy. Compromised hemodynamic state was the most common precipitating event in four patients. Other recognized precipitating events included surgical interventions, decompensated heart failure, gastrointestinal bleeding from gastric malignancy and methotrexate. Endoscopic findings revealed diffuse and circumferential black distal esophagus with abrupt transition at gastroesophageal junction and variable proximal extension at presentation. The 1-month mortality rate was 30%, mostly from severe underlying illness. In conclusion, acute esophageal necrosis is a rare cause of upper gastrointestinal bleeding that should be suspected in older patients with multiple comorbidities. Although associated with a high mortality rate, appropriate treatment may result in favorable outcome in most patients.

The Black Esophagus

Acute esophageal necrosis (AEN), commonly referred to as black esophagus, is a rare clinical condition resulting from a combination of ischemic insult and thromboembolic injury to the esophagus. It is characterized by the circumferential black appearance of the esophagus. The risk factors for the development of AEN include coronary artery disease (CAD), diabetes mellitus, hypertension, malignancy, and alcohol use disorder. The treatment is directed at correcting the underlying medical conditions, supportive measures, and gastric acid suppression.

We present the case of a 60-year-old female with multiple medical comorbidities who was detected to have a black esophagus during the evaluation of anemia.

Black oesophagus, upside-down stomach and cameron lesions: cascade effects of a large hiatal hernia

Acute oesophageal necrosis, black oesophagus (BE) or Gurvits syndrome (GS) is a rare form of severe oesophagitis appearing as a striking circumferential discolouration of distal mucosa with various proximal extensions abruptly terminating at the gastro-oesophageal junction. It is most commonly associated with acute exacerbations of medical comorbidities, while associations with altered gut anatomy are rare. We present a unique constellation of BE, Cameron ulcers (CU), and gastric volvulus from a large paraesophageal hiatal hernia. Our patient recently recovered from COVID-19 and was malnourished and frail, while the expanding paraesophageal hiatal hernia turned into an acute organoaxial gastric volvulus with accompanying outlet obstruction. In low-flow post-COVID coagulopathic states, compensatory mechanisms may lack against gastric stunning and sudden massive reflux on the oesophagus. We additionally performed a systematic review and discovered additional cases with coexistent volvulus and paraesophageal hernia, although there are no previous reports of BE with CU, which makes this study the first.

Acute esophageal necrosis as a complication of diabetic ketoacidosis: A case report

BACKGROUND

Acute esophageal necrosis (AEN) is a rare condition that has been associated with low volume states, microvascular disease, gastrointestinal (GI) mucosal damage, and impaired GI motility. It has been linked in case reports with diabetic ketoacidosis (DKA) and is commonly associated with GI bleeding (GIB).

CASE SUMMARY

We report a case of endoscopy confirmed AEN as a complication of DKA in a 63-year-old Caucasian male without any overt GIB and a chief complaint of epigastric pain. Interestingly, there was no apparent trigger for DKA other than a newly started ketogenic diet two days prior to symptom onset. A possible potentiating factor for AEN beyond DKA is the recent start of a Glucagon-like peptide-1 receptor agonist (GLP-1 RA), though they have not been previously connected to DKA or AEN. The patient was subsequently treated with high dose proton pump inhibitors, GLP-1 RA was discontinued, and an insulin regimen was instituted. The patient’s symptoms improved over the course of several weeks following discharge and repeat endoscopy showed well healing esophageal mucosa.

CONCLUSION

This report highlights AEN in the absence of overt GIB, emphasizing the importance of early consideration of EGD.

Acute Esophageal Necrosis Early after Renal Transplantation

Background

Acute esophageal necrosis (AEN) is defined as a diffused black discoloration of the esophageal mucosa involving mainly the distal part of the esophagus. It is considered a rare clinical entity with a high mortality rate. The etiology of AEN is unknown, but it has been correlated to many causes such as malignancies, infections, and hemodynamics instability. Here, we report a case of a patient developing AEN a few days after kidney transplantation. Case Presentation. A 57-year-old male was admitted electively for kidney transplantation that he received from his son. The surgery was complicated with a significant drop in blood pressure but otherwise was uneventful. The patient was showing good signs of recovery but then suffered from significant hematemesis. An urgent upper esophagogastroduodenoscopy revealed black discoloration of the esophageal mucosa in keeping with AEN. The patient was treated with proton pump inhibitors infusion and started empirically on antivirals and antifungals. The patient's condition improved in regards to the AEN; nonetheless, the complications resulted in graft loss, and the patient returned to hemodialysis.

Conclusion

AEN is a critical condition that mandates early intervention. Identifying high-risk populations may aid in early anticipation and diagnosis. Patients with chronic kidney disease are at risk of atherosclerosis leading to a low flow state which is exacerbated during renal transplantation surgery, especially if the procedure was complicated with a drop in blood pressure.

Acute Esophageal Necrosis Secondary to a Paraesophageal Hernia

Acute esophageal necrosis (AEN) or “black esophagus” is a rare clinical entity caused by necrosis of distal esophageal mucosa stemming from esophageal ischemia. Possible etiologies are broad but most commonly include possible triggers of low-flow vascular states in the esophagus, including infections, broad-spectrum antibiotic use, and gastric volvulus, among others. Patients most commonly present clinically with acute onset hematemesis and melena. Here, we describe a patient who initially presented with multiple nonspecific gastrointestinal symptoms, including abdominal pain and nausea, that progressed over a 10-day period, culminating in multiple episodes of hematemesis prior to presentation. Endoscopic evaluation confirmed the diagnosis of AEN and unveiled a possible paraesophageal hernia (PEH) as the causative factor. A subsequent videofluoroscopic barium swallow was utilized to better characterize the upper gastrointestinal anatomy and confirmed the PEH as a likely etiology. Esophagogastroduodenoscopy (EGD) can often identify PEH independently, but in patients with AEN secondary to a possible, but unclear, PEH on EGD, a videofluoroscopic barium swallow is an appropriate and useful next step in confirming the diagnosis. While treatment of AEN traditionally involves fluid resuscitation, intravenous protein pump inhibitors, and total parenteral nutrition, surgical intervention is often indicated in patients who have a contributing and symptomatic PEH.

Acute Esophageal Necrosis (Black Esophagus): An Autopsy Case Series

Introduction:

Acute esophageal necrosis (AEN), also known as black esophagus and acute necrotizing esophagitis, is a rare pathologic finding of unknown etiology. It was first characterized as diffuse, circumferential black discoloration of the esophageal mucosa that affects predominantly the distal esophagus with sharp transition to normal-appearing mucosa at the gastroesophageal junction. Case frequency of AEN remains low and mainly found incidentally, with up to 0.2% in autopsy and endoscopy studies. Men are 4 times more commonly affected and overall mortality is approximately 32%.

Methods:

Black esophagus was incidentally found during ten forensic autopsy cases. Complete autopsies with photographs, histological examination, and toxicological analysis were performed. Case background information was reviewed. A review of literature was done, with research criteria including previous case reports, diagnosis, and autopsy, endoscopic, and microscopic findings of AEN.

Results:

Nine of ten deceased were male, with an age range of 26 to 67 years old. The most common preexisting pathological condition was chronic alcohol consumption, seen in six of ten cases, and in eight cases, the death occurred suddenly at home. “Classic” black esophagus was only seen in four cases. Upper gastrointestinal hemorrhage due to acute necrotizing esophagitis was established as the immediate cause of death in six of ten cases.

Discussion:

This case series demonstrates ten cases of AEN with variation in appearance, yet diagnosis supported by histology, ancillary testing, and case information. The case frequency was higher than previously reported, 0.7%, suggesting that the prevalence of AEN may be underestimated, especially in forensic death investigations.

Epidemiology, Pathogenesis, and Clinical Manifestations of Acute Esophageal Necrosis in Adults

Acute esophageal necrosis (AEN), also termed "black esophagus," is a unique and uncommon occurrence observed in severely sick patients. Other terminologies include acute necrotizing esophagitis and Gurvits syndrome. This condition is described as a darkened distal third of the esophagus observed on endoscopy and presents as an upper gastrointestinal (GI) bleed, difficulty swallowing, abdominal pain, fever, syncope, nausea, and vomiting. The etiology of AEN has been linked to several possibilities, such as excessive gastric acid reflux, hypoperfusion, and ischemia due to impaired vascular supply and hemodynamic instability. Risk factors include increased age, sex (male), heart disease, hemodynamic insufficiency, alcohol use, gastric outlet obstruction, diabetic ketoacidosis (DKA), malnutrition, renal disease, and trauma which also have the propensity to complicate disease course. An esophageal biopsy is not warranted. Treatment of AEN is comprised of supportive management with intravenous fluids, proton pump inhibitors (PPI), sucralfate, parenteral nutrition, and antacids. Management of preexisting comorbidities associated with AEN is crucial to prevent exacerbation of the disease course that could result in a poor prognosis and increased mortality rates. This literature review article comprises epidemiology, etiology, pathogenesis, diagnosis, and management of AEN.

Acute oesophageal necrosis: an important differential in the elderly population with haematemesis

Acute oesophageal necrosis is a rare cause of haematemesis associated with high mortality and morbidity in elderly patients with multiple comorbidities. Acute oesophageal necrosis is thought to be caused by a combination of hypoperfusion, vascular disease and duodenal disease causing transient gastric outlet obstruction and therefore reflux of gastric contents. The subsequent necrosis is associated with significant morbidity and mortality. We present a case of an 83-year-old man presenting with sepsis secondary to gallstone cholangitis, who developed haematemesis 2 days post admission. Oesopho-gastro-duodenoscopy demonstrated necrosis to the oesophagus and duodenal ulceration. This was the first case of acute oesophageal necrosis observed within our hospital. We review the literature on the management of acute oesophageal necrosis and discuss the impact of acute oesophageal necrosis and its complications on the patient's long-term outcome.

Sudden Esophageal Necrosis and Mediastinitis Associated with Invasive Candidiasis: A Case Report

BACKGROUND Esophageal necrosis is a rare entity characterized by the presence of extensive circumferential necrosis of the esophagus. It generally affects older adults who have associated chronic pathologies and has a reported mortality rate of approximately 32%. Most patients with esophageal necrosis have a complex clinical course. CASE REPORT We present the case of a 37-year-old man with idiopathic chronic renal failure who presented to the Emergency Department with sudden esophageal necrosis and mediastinitis, associated with invasive candidiasis. Diagnosis was challenging owing to the rarity of the condition. The patient required intensive care management and multiple surgical procedures. CONCLUSIONS Esophageal necrosis is an uncommon pathology that can be fatal because of associated complications. Its pathophysiology is unclear, and its treatment is based on the control of local injury and signs and symptoms. Acute esophageal necrosis associated with invasive Candida sp. infection is even more infrequent, with only a few cases reported in the literature.

Black esophagus: a syndrome of acute esophageal necrosis associated with active alcohol drinking

Black esophagus, also known as acute esophageal necrosis (AEN) syndrome, is a rare entity characterized by patchy or diffuse circumferential black pigmentation of the esophageal mucosa from ischemic necrosis. It may present with life-threatening upper gastrointestinal hemorrhage resulting in high mortality in immunocompromised patients. Advanced age with multiple comorbidities compounded with compromised hemodynamic states are poor prognostic factors. Findings on laboratory work-up and radiological imaging are non-specific. After initial resuscitation, endoscopic evaluation and histological examination of esophageal biopsy are diagnostic. Early recognition and aggressive resuscitation are the fundamental principles for the management of AEN and better outcome of the disease. We report a case of a 56-year-old woman with diabetes mellitus, gastro-esophageal reflux disease, and active alcohol binging who presented with hematemesis and acute epigastric pain due to AEN. This case illustrates a rare etiology of AEN due to active alcohol drinking, which may be overlooked. Physician awareness about this etiology is important as early recognition and timely management may improve survival.

Wischnewski Spots and Black Oesophagus in Suspected Fatal Hypothermia in a Brown Howler Monkey (Alouatta guariba clamitans) and a Rabbit (Oryctolagus cuniculus)

Fatal hypothermia represents a diagnostic challenge in veterinary pathology. Wischnewski spots (WS) and black oesophagus (BO) have been described in human cases of fatal hypothermia but rarely in animals. We now describe WS and BO in suspected fatal hypothermia in a free-ranging brown howler monkey (Alouatta guariba clamitans) and a pet rabbit (Oryctolagus cuniculus). Both animals had dark spots resembling WS on the gastric mucosa and the monkey also had BO with haematin deposition. In both cases, stress factors and relatively cold environmental conditions were present prior to death.

The dark side of the esophagus

Acute esophageal necrosis (AEN), also known as “black esophagus,” is an entity characterized by the circumferential black appearance of esophageal mucosa, usually associated with hypoperfusion and gastric outlet obstruction. This entity has a reported prevalence of up to 0.2%, affecting predominantly elderly men with multiple comorbidities. Most cases resolve with conservative treatment with no need of surgical intervention. However, the overall prognosis is poor, with mortality reaching one-third of cases due to the patient’s underlying illness. In this article we present three cases of patients with AEN.

Acute esophageal necrosis complicated by refractory stricture formation

Acute esophageal necrosis (AEN) is a rare presentation of severe esophageal injury. The optimal long‐term management of complications related to AEN, particularly stricture formation, are not well defined. We report a case of AEN in a patient who presented with diabetic ketoacidosis (DKA) and had dysphagia due to refractory stricture formation after mucosal healing occurred. A 62‐year‐old male with diabetes mellitus presented with altered mental status. He was admitted for hypovolemic shock secondary to DKA and treated with vasopressors, fluid resuscitation, and insulin. After resolution of DKA, he reported persistent dysphagia. Upper endoscopy showed circumferential black mucosal discoloration throughout the entire esophagus that spared the gastroesophageal junction. He was diagnosed with AEN and was continued on a proton pump inhibitor and sucralfate with improvement in symptoms. Repeat endoscopy 4 weeks later showed a 10‐cm benign‐appearing stricture in the mid esophagus. He underwent dilation with temporary symptomatic relief; however, recurrence in symptoms has thus far necessitated a total of 10 repeat upper endoscopies, including repeat dilations along with local steroid injection therapy. AEN is a rare presentation of severe esophageal injury and is typically associated with severe hemodynamic compromise. Although most cases resolve with supportive care and mucosal healing, there is little information regarding prognosis and optimal management of complications, such as refractory esophageal strictures. We describe a case of AEN complicated by refractory symptomatic esophageal stricture despite several dilations and intralesional steroid injections and discuss our approach to treatment.

Acute esophageal necrosis after kidney transplantation: A case report

RATIONALE

Acute esophageal necrosis (AEN) is a rare syndrome with characteristic endoscopic and pathologic findings. It usually results from a combination of tissue hypoperfusion, impaired local defense barriers, and massive reflux of gastric contents. We report a case of AEN after a kidney transplant.

PATIENT CONCERNS

A 53-year-old man with hypertension and end-stage renal disease presented with abdominal pain and a single episode of hematemesis 14 days after kidney transplantation.

DIAGNOSIS

Upper endoscopy revealed circumferential black coloration in the mid to lower esophageal mucosa. Esophageal biopsy showed ulcer, and immunostains were negative for viral etiology.

INTERVENTIONS

Conservative management was done with total parenteral nutrition and proton pump inhibitor.

OUTCOMES

The patient experienced no further episodes of hematemesis or abdominal pain and follow-up endoscopy showed remarkable changes from the black mucosa to a red friable mucosa with whitish exudates.

LESSONS

In the case, AEN occurred in the setting of normal blood pressure after major surgery despite the absence of preceding factors such as hypotension and infections. The possibility of AEN should be considered in patients with solid organ transplantation who present with abdominal pain, dysphagia, and hematemesis.

Indocyanine green fluorescence imaging for subtotal esophagectomy due to esophageal stenosis after acute esophageal necrosis: a report of two cases

Although esophageal stricture after acute esophageal necrosis (AEN) is often refractory to dilation therapy, there have been few reports of surgical intervention. We report two rare cases of successful subtotal esophagectomy and esophagogastrostomy for esophageal strictures after AEN using indocyanine green (ICG) fluorescence imaging. In case 1, emergent esophagogastroduodenoscopy (EGD) in a 56-year-old man with coffee-ground emesis revealed black esophageal mucosa in the middle to lower esophagus, indicating AEN. Despite conservative therapy, an esophageal stricture developed after 2 weeks. Repeated endoscopic balloon dilation (EBD) did not resolve the stenosis; esophagectomy was thus performed approximately 6 months after AEN onset. We evaluated the blood flow to the esophagus using ICG fluorescence imaging to determine the proximal surgical resection line. The postoperative course was uneventful. In case 2, an 81-year-old woman with upper gastrointestinal bleeding with hematemesis and chest pain was diagnosed with AEN by EGD and was treated with conservative therapy. An esophageal stricture developed after 3 weeks, and repeated EBD was ineffective. Approximately 2 months after AEN onset, she underwent esophagectomy using ICG fluorescence imaging. The postoperative course was uneventful. Considering that AEN is a blood flow disorder, ICG fluorescence imaging is a useful technology to prevent surgical morbidity.

Black esophagus as an autopsy discovery: a challenging interpretation

Black esophagus is a rare medical condition, characterized by a circumferential blackish discoloration of the distal part of the esophageal mucosa, abruptly ending at the gastroesophageal junction. The etiology is multifactorial since patients suffer from multiple comorbidities. While the mortality rate specifically linked to black esophagus is only around 6%, the mortality rate linked to the underlying comorbidities amounts to 32%.

A series of five cases is provided in which black esophagus was an unexpected discovery at autopsy. Black esophagus is generally considered being a challenge to the forensic pathologist. There are often no other major gross anomalies found at autopsy and information about the patient’s medical history is not always available, which complicates a correct assessment.

We present a review of the literature on black esophagus, limited to reports on deceased patients. The reviewed publications are divided into autopsy and endoscopy series to correctly compare the causes of death.

The aim of this review is to identify a possible divergence in causes of death in autopsy and endoscopy series and additionally to analyze the causes of these differences to enable better assessment and interpretation of black esophagus at forensic autopsies. This paper emphasizes the importance of a minimal knowledge of the victim’s comorbidities and medical record and the use of toxicology and postmortem biochemistry analysis as a valuable tool in investigating the cause of death in the setting of black esophagus.

Acute Esophageal Necrosis (Gurvits Syndrome) Presenting as Globus and Altered Phonation

Patient: Female, 80-year-old

Final Diagnosis: Acute esophageal necrosis • acute pharyngitis • duodenal ulcerations • gastric erosions • gastritis

Symptoms: Dysphagia • emesis • globus • hoarseness • sore throat

Medication:—

Clinical Procedure: Esophagogastroduodenoscopy

Specialty: Gastroenterology and Hepatology

Black Esophagus in the Setting of Alcohol Abuse after External Beam Radiation

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.

Tacrolimus-Induced Acute Esophageal Necrosis

Acute esophageal necrosis (AEN) has been rarely described and has poorly understood pathophysiology although it is thought to be related to mucosal defense barrier disruption. We report a case of AEN in a 71-year-old patient with clinical signs of gastric outlet obstruction along with anemia and sepsis in the setting of a recent kidney transplant. After failing standard supportive measures, tacrolimus was switched to cyclosporin with overall rapid improvement of AEN and concomitant duodenal ulcerations. This case underscores a possible rare adverse effect of a commonly used immunosuppressant agent that, to our knowledge, has not been specifically reported.

Acute Esophageal Necrosis Associated With Methicillin-Resistant Staphylococcus Aureus Septicemia: A Case Report

Acute esophageal necrosis (AEN) is a multifactorial disease with a predilection for elderly male patients with multiple medical problems, including mainly hypoperfusion and malnutrition. The diagnosis is confirmed by biopsy, and AEN is managed conservatively by controlling the underlying illness. We report a case of a 65-year-old man with malnutrition, heart failure secondary to ischemic heart disease, infection with methicillin-resistant Staphylococcus aureus septicemia, and positive herpes simplex serology, who developed upper gastrointestinal (GI) bleeding. Endoscopy confirmed AEN, and he was managed conservatively with antacids, hydration, and antibiotics.

Acute Esophageal Necrosis: A Case Series From a Safety Net Hospital

Acute esophageal necrosis (AEN) or "black esophagus" is a rare clinical condition, endoscopically characterized by diffuse circumferential black esophageal mucosa. Etiologies include hypoperfusion, infections, and corrosive injury. Consideration of this condition as a differential diagnosis is important, as early diagnosis and treatment has implications on survival. In this article, we present four unique cases of acute esophageal necrosis who were managed conservatively.