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Schizas D, Theochari NA, Mylonas KS, Kanavidis P, Spartalis E, Triantafyllou S, Economopoulos KP, Theodorou D, Liakakos T. Acute esophageal necrosis: A systematic review and pooled analysis. World J Gastrointest Surg 2020; 12:104-115. [PMID: 32218893 PMCID: PMC7061242 DOI: 10.4240/wjgs.v12.i3.104] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 12/02/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute esophageal necrosis (AEN) is a rare entity with multifactorial etiology, usually presenting with signs of upper gastrointestinal bleeding.
AIM To systematically review all available data on demographics, clinical features, outcomes and management of this medical condition.
METHODS A systematic literature search was performed with respect to the PRISMA statement (end-of-search date: October 24, 2018). Data on the study design, interventions, participants and outcomes were extracted by two independent reviewers.
RESULTS Seventy-nine studies were included in this review. Overall, 114 patients with AEN were identified, of whom 83 were males and 31 females. Mean patient age was 62.1 ± 16.1. The most common presenting symptoms were melena, hematemesis or other manifestations of gastric bleeding (85%). The lower esophagus was most commonly involved (92.9%). The most widely implemented treatment modality was conservative treatment (75.4%), while surgical or endoscopic intervention was required in 24.6% of the cases. Mean overall follow-up was 66.2 ± 101.8 d. Overall 29.9% of patients died either during the initial hospital stay or during the follow-up period. Gastrointestinal symptoms on presentation [Odds ratio 3.50 (1.09-11.30), P = 0.03] and need for surgical or endoscopic treatment [surgical: Odds ratio 1.25 (1.03-1.51), P = 0.02; endoscopic: Odds ratio 1.4 (1.17-1.66), P < 0.01] were associated with increased odds of complications. A sub-analysis separating early versus late cases (after 2006) revealed a significantly increased frequency of surgical or endoscopic intervention (9.7 % vs 30.1% respectively, P = 0.04)
CONCLUSION AEN is a rare condition with controversial pathogenesis and unclear optimal management. Although the frequency of surgical and endoscopic intervention has increased in recent years, outcomes have remained the same. Therefore, further research work is needed to better understand how to best treat this potentially lethal disease.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
| | - Nikoletta A Theochari
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Prodromos Kanavidis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Stamatina Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens 11527, Greece
| | - Konstantinos P Economopoulos
- Department of Medicine, Surgery Working Group, Society of Junior Doctors, Athens 15122, Greece
- Department of Surgery, Duke University Medical Center, Durham, NC 27708, United States
| | - Dimitrios Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens 11527, Greece
| | - Theodore Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 11527, Greece
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Kim SM, Song KH, Kang SH, Moon HS, Sung JK, Kim SH, Kim KB, Lee SW, Cho YS, Bang KB. Evaluation of prognostic factor and nature of acute esophageal necrosis: Restropective multicenter study. Medicine (Baltimore) 2019; 98:e17511. [PMID: 31593121 PMCID: PMC6799417 DOI: 10.1097/md.0000000000017511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Acute esophageal necrosis (AEN) is a serious disease which can causes gastrointestinal bleeding and death. Although black color change is not essential factor of organ necrosis, AEN is also known as "black esophagus." Because of its rarity, there are limited studies regarding risk factors of mortality and recurrence. Thus, we conducted a multicenter retrospective study in order to evaluate the clinical characteristics of AEN. Method Clinical datum of AEN patients from 7 tertiary hospitals located in Daejeon-Choongcheong province were evaluated based on medical records. Our primary endpoint was risk factors for mortality and the secondary endpoint was risk factors for recurrence and clarifying whether "black esophagus" is a right terminology.Fourty one patients were enrolled. Thirty six patients were male, mean age was 69.5 years. Nine patients had died, and 4 patients showed recurrence. Sepsis and white color change in endoscopy were related to high mortality (Chi-Squared test, P < .05). Old age, high pulse rate, low hemoglobin, and low albumin were also related to high mortality. Unexpectedly, heavy drinking showed favorable a mortality. Septic condition and high pulse rate showed poor mortality in logistic regression test (P < .05). Coexisting duodenal ulcer was related to recurrence (Chi-Squared test, P < .05). There was no difference in the underlying condition except patients with a coexisting cancer and white-form displayed lower hemoglobin level. Conclusion: Our results imply that white color change, septic condition, high pulse rate, and low hemoglobin & albumin are poor prognostic factors in AEN. Further evaluation may help clarify the findings of our study.
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Affiliation(s)
- Sun Moon Kim
- Department of Internal Medicine, College of medicine, Konyang University
| | - Kyung Ho Song
- Department of Internal Medicine, College of medicine, Konyang University
| | - Sun Hyung Kang
- Department of Internal Medicine, Chungnam National University School of Medicine
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine
| | - Jae Kyu Sung
- Department of Internal Medicine, Chungnam National University School of Medicine
| | - Sae Hee Kim
- Department of Internal Medicine, College of medicine, Eulji University
| | - Ki Bae Kim
- Department of Internal Medicine, Chungbuk National University School of Medicine
| | - Seung Woo Lee
- Department of Internal Medicine, Catholic University of Korea School of Medicine
| | - Young Sin Cho
- Department of Internal Medicine, College of medicine, Soonchunhyang University
| | - Ki Bae Bang
- Department of Internal Medicine, College of medicine, Dankook University, Republic of Korea
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Dias E, Santos-Antunes J, Macedo G. Diagnosis and management of acute esophageal necrosis. Ann Gastroenterol 2019; 32:529-540. [PMID: 31700229 PMCID: PMC6826069 DOI: 10.20524/aog.2019.0418] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/26/2019] [Indexed: 02/06/2023] Open
Abstract
Acute esophageal necrosis is a rare syndrome classically characterized by a striking endoscopic image of diffuse and circumferential black mucosal discoloration of distal esophagus, with an abrupt transition at the gastroesophageal junction and variable proximal extension. The typical patient is an older male with general debilitation and multiple comorbidities presenting with hematemesis or melena. The pathophysiology usually involves a combination of esophageal ischemia, backflow injury from gastric chemical contents and impaired mucosal reparative mechanisms associated with debilitated physical states. It may arise in the setting of hemodynamic compromise, diabetic ketoacidosis, hypothermia, alcoholic intoxication, trauma, inflammatory diseases, esophageal local infection, solid organ transplantation, postoperative status, drugs or acute gastric outlet obstruction, usually in the background of a chronic debilitating process, where the concurrent presence of multiple risk factors, including diabetes mellitus, hypertension, malnutrition, malignancy or alcohol abuse, places a patient at higher risk. The characteristic endoscopic appearance establishes the diagnosis. Biopsy is supportive but not required. Management is mainly supportive and consists of correcting coexisting conditions, fluid therapy, bowel rest, intravenous proton pump inhibitor therapy and red blood cell transfusion as needed. Although this is a serious life-threatening condition, appropriate treatment may result in a favorable outcome in the majority of patients.
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Affiliation(s)
- Emanuel Dias
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
| | - João Santos-Antunes
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar de São João, Porto, Portugal
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Orlando D, Carabotti M, Ruggeri M, Esposito G, Corleto VD, Di Giulio E, Annibale B. Occurrence of Acute Oesophageal Necrosis (Black Oesophagus) in a Single Tertiary Centre. J Clin Med 2019; 8:E1532. [PMID: 31554345 PMCID: PMC6832419 DOI: 10.3390/jcm8101532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/19/2019] [Accepted: 09/22/2019] [Indexed: 02/05/2023] Open
Abstract
Acute oesophageal necrosis (AON) is a rare condition characterised by the endoscopic finding of diffuse, circumferential, black mucosal pigmentation of the oesophagus, which typically stops at the gastro-oesophageal junction. This observational study aimed to assess the occurrence, clinical characteristics and outcomes of AON in a consecutive endoscopic cohort in a single tertiary university centre. A retrospective analysis of endoscopic data of upper gastrointestinal endoscopy (UGE) was carried out from 2008 to 2018. Out of 25,970 UGE, 16 patients (0.06%) had AON; 75.0% were men with a median age of 75 years. Almost all patients underwent diagnosis during emergency UGE performed for gastrointestinal bleeding, but one patient was diagnosed during elective UGE for persistent vomiting and diarrhoea. All patients reported one or more pre-existing comorbidities and concomitant acute events. Two patients had AON as the first presentation of Zollinger-Ellison syndrome (ZES). One patient developed an oesophageal stenosis, and another patient presented a relapse of AON. Mortality was 50%, but no patient died as a direct consequence of AON. AON is a rare cause of gastrointestinal bleeding diagnosed mainly during emergency UGE. Our study showed that ZES might manifest with this critical presentation, and endoscopists must be aware of this evidence.
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Affiliation(s)
- Davide Orlando
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy.
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy.
| | - Maurizio Ruggeri
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy.
| | - Gianluca Esposito
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy.
| | - Vito Domenico Corleto
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy.
| | - Emilio Di Giulio
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy.
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy.
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Mostazo-Torres J, Vílchez-Jaimez M, Marín-García D. [Acute necrotising oesophagitis associated with hyperosmolar diabetic coma]. Semergen 2017; 43:e57-e59. [PMID: 28320579 DOI: 10.1016/j.semerg.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/30/2016] [Accepted: 01/10/2017] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - D Marín-García
- Hospital Regional Universitario de Málaga, Málaga, España
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Abstract
Acute esophageal necrosis (AEN), commonly referred to as “black esophagus”, is a rare clinical entity arising from a combination of ischemic insult seen in hemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophago-gastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. AEN may arise in the setting of multiorgan dysfunction, hypoperfusion, vasculopathy, sepsis, diabetic ketoacidosis, alcohol intoxication, gastric volvulus, traumatic transection of the thoracic aorta, thromboembolic phenomena, and malignancy. Clinical presentation is remarkable for upper gastrointestinal bleeding. Notable symptoms may include epigastric/abdominal pain, vomiting, dysphagia, fever, nausea, and syncope. Associated laboratory findings may reflect anemia and leukocytosis. The hallmark of this syndrome is the development of diffuse circumferential black mucosal discoloration in the distal esophagus that may extend proximally to involve variable length of the organ. Classic “black esophagus” abruptly stops at the gastroesophageal junction. Biopsy is recommended but not required for the diagnosis. Histologically, necrotic debris, absence of viable squamous epithelium, and necrosis of esophageal mucosa, with possible involvement of submucosa and muscularis propria, are present. Classification of the disease spectrum is best described by a staging system. Treatment is directed at correcting coexisting clinical conditions, restoring hemodynamic stability, nil-per-os restriction, supportive red blood cell transfusion, and intravenous acid suppression with proton pump inhibitors. Complications include perforation with mediastinal infection/abscess, esophageal stricture and stenosis, superinfection, and death. A high mortality of 32% seen in the setting of AEN syndrome is usually related to the underlying medical co-morbidities and diseases.
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Day A, Sayegh M. Acute oesophageal necrosis: a case report and review of the literature. Int J Surg 2009; 8:6-14. [PMID: 19800431 DOI: 10.1016/j.ijsu.2009.09.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 09/24/2009] [Accepted: 09/27/2009] [Indexed: 01/28/2023]
Abstract
AIMS We discuss a case of acute oesophageal necrosis and undertook a literature review of this rare diagnosis. METHODS The literature review was performed using Medline and relevant references from the published literature. RESULTS One hundred and twelve cases were identified on reviewing the literature with upper gastrointestinal bleeding being the commonest presenting feature. The majority of cases were male and the mean age of presentation is 68.4 years. This review of the literature shows a mortality rate of 38%. CONCLUSION Acute necrotizing oesophagitis is a serious clinical condition and is more common than previously thought. It should be suspected in those with upper GI bleed and particularly the elderly with comorbid illness. Early diagnosis with endoscopy and active management will lead towards an improvement in patient outcome.
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Affiliation(s)
- Andrew Day
- Worthing and Southlands Hospitals NHS Trust, Worthing Hospital, Lyndhurst Road, Worthing BN11 2DH, UK.
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