Black esophagus associated with herpes esophagitis

Herpes Simplex Virus Esophagitis in a Patient Receiving Long-Term Nasal Corticosteroids: A Rare Case

Herpetic esophagitis (HE), primarily caused by the herpes simplex virus (HSV)-1, is most commonly encountered in immunocompromised hosts, although it has been occasionally observed in immunocompetent patients. In the immunocompromised setting, it is typically correlated with human immunodeficiency virus (HIV) infection, malignancy, chemotherapy and radiotherapy, solid organ transplant, as well as the use of systemic corticosteroids and other immunosuppressive agents. We present the case of a 35-year-old patient on hemodialysis due to diabetic nephropathy who, after having received intranasal corticosteroids for three weeks, developed nausea, vomiting, and epigastric pain. Gastroscopy and subsequent biopsy revealed ulcerative esophagitis compatible with herpetic infection. Immunohistochemistry was negative for cytomegalovirus (CMV), while subsequent quantitative polymerase chain reaction (PCR) testing was positive for HSV-1, establishing the diagnosis of HSV esophagitis. After a 14-day course of valacyclovir, complete relief of symptoms was achieved. Herpetic esophagitis may occur in immunocompetent persons, whereas intranasal corticosteroids cannot be ruled out as potential contributors. Symptoms such as odynophagia, dysphagia, and fever in that setting warrant further investigation.

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.

A rare case of oesophageal and gastric fundus necrosis following traumatic splenectomy

Oesophageal and gastric fundus necrosis are rare clinical entities and have not previously been reported concurrently. This case study describes oesophageal and gastric fundus necrosis in a 71-year-old female who developed chest pain post-splenectomy for infected splenic haematoma in the context of a fall. Upper gastrointestinal endoscopy demonstrated oesophageal and gastric fundus necrosis. This was likely due to multiple factors including comorbidities, hypoperfusion, post-splenectomy state and herpes simplex virus oesophagitis. This finding is an important differential in the unwell patient with chest pain post-splenectomy and investigation with upper gastrointestinal endoscopy could be considered in the absence of another cause.

Black esophagus and diabetes: a close relationship

The black esophagus is a rare clinical entity, down to 0.2% in autopsy series and 0.001-0.2% in series of endoscopies. Although it is an entity that has already been reported in the literature, its etiopathogenesis is not completely known. Different theories have been proposed to clarify their cause. One of these theories makes a hypothesis of a viral infection as the underlying cause; this theory can be seen in the literature extensively, but only two cases were reported. The first case is a case with histopathological confirmation of Herpes virus infection. The second is a case in which vascular deterioration has been the main cause of esophageal necrosis. In both cases, diabetes is the factor that determines a bad evolution of the disease.

Diagnosis and management of acute esophageal necrosis

Acute esophageal necrosis is a rare syndrome classically characterized by a striking endoscopic image of diffuse and circumferential black mucosal discoloration of distal esophagus, with an abrupt transition at the gastroesophageal junction and variable proximal extension. The typical patient is an older male with general debilitation and multiple comorbidities presenting with hematemesis or melena. The pathophysiology usually involves a combination of esophageal ischemia, backflow injury from gastric chemical contents and impaired mucosal reparative mechanisms associated with debilitated physical states. It may arise in the setting of hemodynamic compromise, diabetic ketoacidosis, hypothermia, alcoholic intoxication, trauma, inflammatory diseases, esophageal local infection, solid organ transplantation, postoperative status, drugs or acute gastric outlet obstruction, usually in the background of a chronic debilitating process, where the concurrent presence of multiple risk factors, including diabetes mellitus, hypertension, malnutrition, malignancy or alcohol abuse, places a patient at higher risk. The characteristic endoscopic appearance establishes the diagnosis. Biopsy is supportive but not required. Management is mainly supportive and consists of correcting coexisting conditions, fluid therapy, bowel rest, intravenous proton pump inhibitor therapy and red blood cell transfusion as needed. Although this is a serious life-threatening condition, appropriate treatment may result in a favorable outcome in the majority of patients.

Acute necrotizing esophagitis presenting with severe lactic acidosis and shock

Acute necrotizing esophagitis, also known as "black esophagus," is typically characterized by a circumferential, friable black mucosal surface and preferentially involves the distal esophagus. It predominantly affects elderly men and presents as an upper gastrointestinal bleed. We describe a 60-year-old man with an acute upper gastrointestinal bleed and sepsis and subsequently acute necrotizing esophagitis.

"Black Esophagus" and Gastric Volvulus Following Slipped Laparoscopic Adjustable Gastric Band

To review the entity "black esophagus" and sequela of a slipped laparoscopic adjustable band. The patient's history, physical examination, imaging, and endoscopic findings were reviewed. Detailed review of pathophysiology, presentation, diagnosis, management, and natural history was conducted. "Black esophagus," also known as acute esophageal necrosis (AEN), is a rare condition resulting in black discoloration of the mid to distal esophagus with less than a hundred reported cases. It has not been previously documented in bariatric surgery or following laparoscopic adjustable gastric banding. The volvulus was reduced at surgery, and the esophageal changes resolved without sequela. "Black esophagus" is an acute, ominous-appearing condition with a spectrum ranging from superficial mucosal disease to transmural involvement with perforation. Fortunately, esophageal resection is rarely required.

Acute esophageal necrosis

Acute esophageal necrosis (AEN) or "black esophagus" is a rare condition presented by patients with critical state of health and characterized by a darkened esophagus, usually the distal third, in upper digestive endoscopy. The main clinical manifestation is upper gastrointestinal bleeding and there may be abdominal pain, dysphagia, nausea, vomiting, fever and syncope associated. The diagnosis depends on clinical suspicion and performing endoscopy, the biopsy not being required. In this article we present a case of a patient who had lots of comorbidities and developed AEN during a post-operative period, and discuss the importance of AEN in an increasingly ageing population.

Black esophagus: acute esophageal necrosis in fatal haloperidol intoxication

Herein, we present a case of 53-year-old psychotic woman with acute esophageal necrosis (black esophagus), who was found lying on the floor in the living room of her flat. Pillboxes of antipsychotic drugs were located in the bin. External examination of the body was unremarkable. On internal examination, we found acute esophageal necrosis. Histologically, there was complete epithelial necrosis with focal involvement of muscularis mucosae, dense infiltrate of leukocytes, and ulcerations without any viable cells. There was no evidence of underlying organic diseases or trauma. Toxicological analysis revealed a fatal blood level of antipsychotics (haloperidol, zotepine, and chlorprothixene). Death of the deceased was attributed to fatal intoxication with three various types of antipsychotics. As far we know, this is the first described association between so-called black esophagus and fatal blood level of neuroleptics.

Esophageal infarction

Esophageal infarction or acute necrotizing esophagitis is a rare condition that has a dramatic endoscopic appearance of a "black esophagus." The esophageal involvement can vary from the distal third to the total esophagus. Excluding corrosive injury and other well-known rare causes of black esophagus, the etiology of this condition is unknown. Ischemia due to hypoperfusion state is thought to play a central role in the pathogenesis. The treatment is supportive with acid suppression and gastrointestinal rest. Mortality is high due to comorbid conditions.

Black esophagus: Acute esophageal necrosis syndrome

Acute esophageal necrosis (AEN), commonly referred to as “black esophagus”, is a rare clinical entity arising from a combination of ischemic insult seen in hemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophago-gastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. AEN may arise in the setting of multiorgan dysfunction, hypoperfusion, vasculopathy, sepsis, diabetic ketoacidosis, alcohol intoxication, gastric volvulus, traumatic transection of the thoracic aorta, thromboembolic phenomena, and malignancy. Clinical presentation is remarkable for upper gastrointestinal bleeding. Notable symptoms may include epigastric/abdominal pain, vomiting, dysphagia, fever, nausea, and syncope. Associated laboratory findings may reflect anemia and leukocytosis. The hallmark of this syndrome is the development of diffuse circumferential black mucosal discoloration in the distal esophagus that may extend proximally to involve variable length of the organ. Classic “black esophagus” abruptly stops at the gastroesophageal junction. Biopsy is recommended but not required for the diagnosis. Histologically, necrotic debris, absence of viable squamous epithelium, and necrosis of esophageal mucosa, with possible involvement of submucosa and muscularis propria, are present. Classification of the disease spectrum is best described by a staging system. Treatment is directed at correcting coexisting clinical conditions, restoring hemodynamic stability, nil-per-os restriction, supportive red blood cell transfusion, and intravenous acid suppression with proton pump inhibitors. Complications include perforation with mediastinal infection/abscess, esophageal stricture and stenosis, superinfection, and death. A high mortality of 32% seen in the setting of AEN syndrome is usually related to the underlying medical co-morbidities and diseases.

Acute oesophageal necrosis: a case report and review of the literature

AIMS

We discuss a case of acute oesophageal necrosis and undertook a literature review of this rare diagnosis.

METHODS

The literature review was performed using Medline and relevant references from the published literature.

RESULTS

One hundred and twelve cases were identified on reviewing the literature with upper gastrointestinal bleeding being the commonest presenting feature. The majority of cases were male and the mean age of presentation is 68.4 years. This review of the literature shows a mortality rate of 38%.

CONCLUSION

Acute necrotizing oesophagitis is a serious clinical condition and is more common than previously thought. It should be suspected in those with upper GI bleed and particularly the elderly with comorbid illness. Early diagnosis with endoscopy and active management will lead towards an improvement in patient outcome.

Black esophagus associated with alcohol abuse

Black esophagus is a rare condition of the esophagus that manifests as endoscopic findings of black-colored esophageal mucosa, which is usually caused by acute esophageal necrosis. We report a case of alcoholic patient who developed black esophagus. The 85-year-old man was admitted to Severance Hospital due to copious hematemesis over 2 days. Upper gastrointestinal endoscopy showed black-colored mucosa in the distal esophagus. Endoscopic biopsies of the esophagus revealed necrotic tissue, without any viable cells. Follow-up upper gastrointestinal endoscopy performed after supportive care with a proton-pump inhibitor, sucralfate, and total parenteral nutrition resulted in the remarkable healing of the esophageal wall with no complications.

Herpes simplex virus and the alimentary tract

Herpes simplex virus (HSV) infection is well known as a sexually transmitted disease. However, relatively little has been published concerning the presentations and treatment of HSV infection within the gastrointestinal tract, where HSV most commonly affects the esophagus in both immunocompromised and immunocompetent patients. HSV proctitis is not uncommon and occurs primarily in males having sex with males. In patients with normal immune systems, gastrointestinal HSV infections are generally self-limited and rarely require antiviral therapy. Treatment of infection is suggested for immunocompromised patients, though no large randomized controlled trials have been performed. This article reviews the manifestations of HSV infection within the luminal gastrointestinal tract and options for diagnosis and treatment.

Acute esophageal necrosis (black esophagus) in the renal transplant recipient: manifestation of primary cytomegalovirus infection

We report a severe case of cytomegalovirus (CMV) esophagitis in a renal transplant recipient presenting as acute esophageal necrosis (AEN, 'black esophagus'). AEN is an uncommon entity that is a result of mucosal necrosis and has been described only a few times previously. To our knowledge, this is the first report of AEN due to a CMV infection. The disease was manifested by abdominal and epigastric pain, thrombocytopenia, leukopenia, and elevated liver enzymes. Upper endoscopy showed acute esophageal necrosis. Ganciclovir therapy was initiated immediately and resulted in a complete remission of symptoms. We conclude that the possibility of CMV infection should be suspected in any patient presenting with cytopenia, elevated liver enzymes, and epithelial gastrointestinal lesions in the first 6 months after transplantation, and that early viral detection and antiviral therapy can be lifesaving.

Acute esophageal necrosis: a rare syndrome

BACKGROUND

Acute esophageal necrosis, which presents as a black esophagus on endoscopy, is a rare disorder that is poorly described in the medical literature. In this study, we analyze all cases reported to date to define risk factors, clinical presentation, endoscopic features, histologic appearance, treatment, complications, outcome and etiopathogenesis of the disease and to describe a distinct medical syndrome and propose a staging system.

METHODS

We searched Medline and PubMed from January 1965 to February 2006 for English-language articles using the key words "acute esophageal necrosis," "necrotizing esophagitis," and "black esophagus."

RESULTS

A total of 88 patients were reported in the literature during the 40 years, 70 men and 16 women with an average age of 67 years. Patients were generally admitted for gastrointestinal bleeding and cardiovascular event/shock. Patients presented with hematemesis and melena in more than 70% of the cases. Upper endoscopy showed black, diffusely necrotic esophageal mucosa predominantly affecting the distal third of the organ. Necrosis was confirmed histologically in most cases. Complications included strictures or stenoses, mediastinitis/abscesses, and perforations. Overall mortality was 31.8%.

CONCLUSIONS

This study provides a structured approach to identifying risk factors, diagnosis, and pathogenesis of the acute esophageal necrosis. Risk factors include age, male sex, cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol ingestion, malnutrition, diabetes, renal insufficiency, hypoxemia, hypercoagulable state, and trauma. Mechanism of damage is usually multifactorial secondary to ischemic compromise, acute gastric outlet obstruction, and malnutrition. Overall, acute esophageal necrosis should be viewed as a poor prognostic factor, associated with high mortality from the underlying clinical disease.

Black esophagus: report of six cases and review of the literature, 1963-2003

Black esophagus is the uncommon endoscopic finding of extensive black discoloration of the esophageal mucosa, usually from acute esophageal necrosis. Six cases of black esophagus were seen at Mayo Clinic (Rochester, Minnesota, USA) from 1997 through 2003, and 46 cases were reported in the English-language literature from 1963 through 2003. We studied the demographics, clinical features, and outcomes of these 52 cases of black esophagus. Age and sex were known for 50 patients: the mean (SD) age was 65 years (19), and 42 patients (84%) were men. Symptoms were known for 51 patients: the most common symptom was upper gastrointestinal tract bleeding, occurring in 40 patients (78%). All 52 patients had at least one comorbid condition (with most having two or more), including duodenal ulcer in 17 (33%), cancer in 15 (29%), renal insufficiency in 15 (29%), and diabetes mellitus in 14 (28%). The suspected cause of black esophagus was reported for 40 patients: ischemia in 22 (55%); massive gastroesophageal reflux in seven (18%); and esophageal infection (Lactobacillus acidophilus, herpes simplex, Candida albicans) in four (10%). Most patients received supportive therapy, particularly acid suppression therapy. Of the 47 patients for whom outcomes were known, 17 (36%) died. There were no statistically significant differences between survivors and non-survivors. Black esophagus typically occurs in older men with at least one comorbid condition; a substantial number of patients die. Although the underlying mechanism leading to black esophagus is unknown, clinicians caring for patients with black esophagus should focus on optimizing perfusion, minimizing acid reflux, and treating esophageal infection if present.

Acute necrotizing esophagitis: role of nonsteroidal anti-inflammatory drugs

BACKGROUND

Acute necrotizing esophagitis (ANE) is a rarely described entity that is thought to be a cause of upper gastrointestinal (UGI) bleeding, The present study examined the incidence of ANE among patients with UGI bleeding, as well as the clinical features of ANE, and the coexisting illnesses and medication histories of ANE patients.

METHODS

A retrospective analysis of clinical and endoscopic findings and the clinical course in 16 patients with ANE was carried out over a 3-year period.

RESULTS

We observed 16 patients (6%) of ANE in 239 patients with UGI bleeding during the 3-year period. The average age of the patients was 62.5 years. The lesions predominantly affected the lower third of the esophagus, and hiatal hernia was the most common (63%) coexisting endoscopic finding. All patients had coexisting disease. Fifty percent of patients with ANE (eight patients) had taken nonsteroidal anti-inflammatory drugs (NSAIDs). ANE also occurred in four patients with diabetic ketoacidosis. Supportive therapy, including parenteral nutrition and administration of a proton pump inhibitor, was effective.

CONCLUSIONS

ANE is more common than has been previously reported, and it should be included in the differential diagnosis of UGI bleeding. ANE could be characterized as an "acute esophageal mucosal lesion," particularly in aged patients with hiatal hernia and among those who consume NSAIDs.

Acute esophageal necrosis caused by alcohol abuse

Acute esophageal necrosis (AEN) is extremely rare and the pathogenesis of this is still unknown. We report a case of AEN caused by alcohol abuse. In our case, the main pathogenesis could be accounted for low systemic perfusion caused by severe alcoholic lactic acidosis. After the healing of AEN, balloon dilatation was effective to manage the stricture.

Black oesophagus: a rare disorder with potentially fatal outcome. A forensic pathological approach based on five autopsy cases

Black oesophagus is a rare pathological condition of unknown aetiology characterised by a full length, circumferential black discolouration of the entire oesophageal mucosa. The disease is sporadically encountered during upper gastrointestinal endoscopy. We used conventional histology, enzyme histochemistry and immunohistology to examine five autopsy cases (four males, one female; age range 43-86 years) of black oesophagus. On microscopical examination, the esophageal mucosa was entirely necrotic with demarcation by a leukocytic infiltrate in the upper submucosa. This infiltrate was dominated by neutrophilic granulocytes and scattered macrophages lacking haemosiderin deposits, placing the noxious mucosal injury in a time frame of approximately 24-72 h prior to death. Black oesophagus was established as the immediate cause of death in one case due to desanguination from the oesophagus and significantly contributed to the fatal outcome in a second case. Apart from a history of chronic alcohol consumption in four cases, no other pre-existing pathological or debilitating conditions could be established. The remarkably consistent pathomorphological picture of the disease seems to be the result of impaired microcirculation of the oesophageal mucosa due to prolonged hypotension of variable aetiology. The diagnosis of black oesophagus requires exclusion of other causes such as ingestion of caustic materials and should be based on histological examination.

Acute esophageal necrosis and liver pathology, a rare combination

Acute esophageal necrosis (AEN) or “black esophagus” is a clinical condition found at endoscopy. It is a rare entity the exact etiology of which remains unknown. We describe a case of ‘black esophagus’, first of its kind, in the setting of liver cirrhosis and hepatic encephalopathy.

L'œsophage noir, une complication exceptionnelle du patient de réanimation

We report a new case of acute necrotizing oesophagitis, diagnosing on a patient hospitalised in intensive care unit. This pathology is still a rare event; the definition excludes patients with a history of recent caustic ingestion. Oesophageal necrosis can be diagnosed at endoscopy by the presence of black necroting appearing oesophagus. Contrary to the caustic oesophagitis whose treatment is often surgical, treatment of the acute necrotizing oesophagitis is primarily medical. The prognosis for patients who develop acute necrotizing oesophagitis is generally poor, even if one can hope for the cure without after-effect of it.

Black Esophagus

Black esophagus is a rare, relatively newly described, and usually incidental finding. The differential diagnosis includes several disease states, including ischemia, which has been implicated in acute necrotizing esophagitis. Several theories have been proposed to explain its etiology.

[Acute necrotizing injuries of the upper gastrointestinal tract]

Because of the rich vascular supply and the density of the intramural vascular network in the upper gastrointestinal tract, acute necrotizing injuries at this site are exceptional. However, low-flow states secondary to certain severe systemic diseases can cause ischemic mucosal damage that finally leads to acute local necrosis. Two cases of acute necrotizing lesions in the esophagus and stomach are presented, together with their endoscopic and pathologic characteristics. The pathogenic, clinical and follow-up features of these injuries are also discussed.

Acute esophageal necrosis: a 1-year prospective study

BACKGROUND

A prospective 1-year study was conducted to assess the frequency, clinical spectrum, histologic description, and follow-up of acute esophageal necrosis unrelated to ingestion of caustic or corrosive agents.

METHODS

The diagnosis of acute esophageal necrosis was based on a diffusely black esophagus at endoscopy and typical histologic features of diffuse mucosal and submucosal necrosis. Ingestion of caustic and corrosive agents was excluded in all patients. Medical history, associated diseases, and clinical symptoms were recorded for each patient. Nutritional status was evaluated based on clinical and biochemical parameters. Treatment included short-term parenteral nutrition and intravenous administration of a pump proton inhibitor. A second endoscopy was performed when possible at 2 weeks after presentation to assess regression of acute esophageal necrosis.

RESULTS

Among 3900 patients who underwent EGD, 8 (0.2%) with acute esophageal necrosis were identified. Nutritional status was poor for 6 patients. Complete resolution of acute esophageal necrosis without further recurrence was observed in 4. No esophageal strictures appeared during follow-up. Four patients died, but no death was directly related to acute esophageal necrosis.

CONCLUSION

Acute esophageal necrosis is not as infrequent an endoscopic finding as has been reported. Acute esophageal necrosis appears to be associated with poor general health status and is not a purely local phenomenon.

Black esophagus: should it be considered an unfavorable prognostic factor?

Black esophagus is a rare condition, reported for the first time in 1990. It is always noted in severely compromised patients. The diagnosis is possible using endoscopy. An esophageal ischemic injury should be considered. It is important that a differential diagnosis is made with consideration of other necrotic conditions of the esophagus. Only supportive treatment and the improvement of the associated disease appear possible.