Diagnosis and management of acute esophageal necrosis

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

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

Acute Esophageal Necrosis: A Successfully Managed Case

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

Markers of Prognosis for Acute Esophageal Necrosis: A Systematic Review

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Key Content and Findings

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

Conclusions

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

Acute necrotizing duodenitis in diabetic ketoacidosis

Acute necrotizing esophagitis (ANE), acute necrotising duodenitis (AND), and Wishnesky's lesions (WLs) are three peculiar upper gastrointestinal pathologies that can be seen in death from diabetic ketoacidosis (DKA). Amongst these three, AND has only been recently described. Morphologically, ANE and AND present as generalized black discoloration of the intestinal tract, and florid necrosis and inflammation. Whereas WLs are discrete black lesions in the stomach with necrosis and muted inflammation. We report a case of isolated AND with an unusual morphology not previously reported. A man in his 60s was found dead at home who died from pneumonia complicated by DKA. The gastrointestinal tract showed isolated patchy and discrete AND in which macroscopically resembled WLs, but microscopy resembled ANE with florid necrosis and acute inflammation. This case, together with the literature, documented AND can be macroscopically diffuse or discrete resembling ANE or WLs respectively but microscopically resemble ANE. Furthermore, the potential of these lesions being found in isolation in DKA raises the possibility of both general and local mechanisms playing a role on their morphology and presentation.

A Case of Metastatic Urothelial Carcinoma-Associated Acute Esophageal Necrosis

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

Jag1/2 maintain esophageal homeostasis and suppress foregut tumorigenesis by restricting the basal progenitor cell pool

Basal progenitor cells are crucial for maintaining foregut (the esophagus and forestomach) homeostasis. When their function is dysregulated, it can promote inflammation and tumorigenesis. However, the mechanisms underlying these processes remain largely unclear. Here, we employ genetic mouse models to reveal that Jag1/2 regulate esophageal homeostasis and foregut tumorigenesis by modulating the function of basal progenitor cells. Deletion of Jag1/2 in mice disrupts esophageal and forestomach epithelial homeostasis. Mechanistically, Jag1/2 deficiency impairs activation of Notch signaling, leading to reduced squamous epithelial differentiation and expansion of basal progenitor cells. Moreover, Jag1/2 deficiency exacerbates the deoxycholic acid (DCA)-induced squamous epithelial injury and accelerates the initiation of squamous cell carcinoma (SCC) in the forestomach. Importantly, expression levels of JAG1/2 are lower in the early stages of human esophageal squamous cell carcinoma (ESCC) carcinogenesis. Collectively, our study demonstrates that Jag1/2 are important for maintaining esophageal and forestomach homeostasis and the onset of foregut SCC.

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

Background

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

Case report

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

Conclusion

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

LEARNING POINTS

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

Black Esophagus: A Rare Case of Acute Esophageal Necrosis

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

A View in the Dark: Two Cases of Acute Esophageal Necrosis in the Setting of Diabetic Ketoacidosis

Acute esophageal necrosis (AEN), also known as Gurvits syndrome, is a rare and potentially life-threatening condition characterized by necrosis of the esophageal mucosa. Acute esophageal necrosis is often associated with critical conditions, such as myocardial infarction, diabetic ketoacidosis (DKA), coronavirus disease 2019 (COVID-19) infection, or post-surgical complications. Patients typically present with nausea, hematemesis, acute dysphagia, and melena. Given its high mortality rate, prompt detection with upper endoscopy and early initiation of treatment are crucial. Most cases of Gurvits syndrome are managed conservatively using intravenous fluids, proton pump inhibitors, and antibiotics. Herein, we present a case series of AEN in the setting of DKA. Both patients received supportive care and were discharged in a stable condition.

Black esophagus

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

Black esophagus as an uncommon cause of gastrointestinal bleeding

Black esophagus (BE) or Acute esophageal necrosis (AEN) is rare clinical entity with an estimated incidence of 0.01-0.2% of patiens undergoing esophagogastroduodenoscopy (EGD). BE is characterized by circumferential blackish coloration of the mucosa, with abrupt interruption at the esophagogastric junction level, secondary to hypoperfusion and ischemia. Upper gastrointestinal hemorrhage is the most common presentation (70-90%), being a rare cause of it. We present 3 cases that were admitted in our center for hematemesis.

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

Background

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

Case Description

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

Conclusions

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

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

Introduction

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

Case Presentation

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

Conclusion

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

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

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

Evaluation of Esophageal Dysphagia in Elderly Patients

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

C. perfringens Blood Stream Infection due to Nontransmural Ischemia of the Esophagus, Stomach, and Left Colon: Case Report

We report the case of a 74-year-old female with abdominal pain, tarry stools, and tachycardia. Previous history included diabetes mellitus with micro- and macroangiopathy. Imaging revealed portal gas, left sided colitis, and emphysematous gastritis, besides severe atherosclerosis with subtotal celiac trunk occlusion and moderate stenosis of the inferior mesenteric artery. Upper endoscopy revealed findings consistent with focal necrotizing gastritis at the greater curvature and acute esophageal necrosis. Blood cultures immediately grew Clostridium perfringens. The patient was treated with broad spectrum antibiotics and was discharged after 21 days in the hospital. This case demonstrates the rare coincident occurrence of nontransmural ischemia of the left colon, the esophagus, and the stomach as a result of low-flow circulatory compromise, which then precipitated C. perfringens associated emphysematous gastritis and blood stream infection.

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

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

Acute Esophageal Necrosis 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.

Decompression Illness in a Scuba Diver With Significant Esophageal Injury

Scuba divers are at risk of decompression illness, of which arterial gas embolism is the most feared consequence. Severe complications involving the gastrointestinal tract are rare. In this report, we describe a case of an experienced scuba diver who was forced to rapidly ascend because of a mechanical failure. His course was complicated by severe esophageal mucosal injury including multiple ulcerations. Although he improved clinically, an esophageal stricture subsequently formed, which required dilation. This seems to be the first case report of significant esophageal injury resulting from decompression illness in a scuba diver.

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.

Esophageal regeneration following surgical implantation of a tissue engineered esophageal implant in a pediatric model

Diseases of the esophagus, damage of the esophagus due to injury or congenital defects during fetal esophageal development, i.e., esophageal atresia (EA), typically require surgical intervention to restore esophageal continuity. The development of tissue engineered tubular structures would improve the treatment options for these conditions by providing an alternative that is organ sparing and can be manufactured to fit the exact dimensions of the defect. An autologous tissue engineered Cellspan Esophageal Implant^TM (CEI) was surgically implanted into piglets that underwent surgical resection of the esophagus. Multiple survival time points, post-implantation, were analyzed histologically to understand the tissue architecture and time course of the regeneration process. In addition, we investigated CT imaging as an “in-life” monitoring protocol to assess tissue regeneration. We also utilized a clinically relevant animal management paradigm that was essential for long term survival. Following implantation, CT imaging revealed early tissue deposition and the formation of a contiguous tissue conduit. Endoscopic evaluation at multiple time points revealed complete epithelialization of the lumenal surface by day 90. Histologic evaluation at several necropsy time points, post-implantation, determined the time course of tissue regeneration and demonstrated that the tissue continues to remodel over the course of a 1-year survival time period, resulting in the development of esophageal structural features, including the mucosal epithelium, muscularis mucosae, lamina propria, as well as smooth muscle proliferation/migration initiating the formation of a laminated adventitia. Long term survival (1 year) demonstrated restoration of oral nutrition, normal animal growth and the overall safety of this treatment regimen.

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.

Acute esophageal necrosis induced by immune checkpoint inhibitors

A 73-year-old man with chronic obstructive pulmonary disease presented to the emergency department with a two-day history of coffee ground emesis and melena. The patient had been treated with the PD-1 inhibitor nivolumab because of a lung adenocarcinoma stage IV. On examination, he was tachycardic (130 beats per minute) and hypotensive (95/55 mm Hg). Laboratory studies revealed anemia (6.9 g/dL), leukocytosis, and hyper-lactatemia (lactate 6.3 mmol/l). Upper gastrointestinal endoscopy showed diffuse circumferential blackish, necrotic-appearing mucosa of the first third of the esophagus. These findings were consistent with the diagnosis of acute esophageal necrosis (AEN). Biopsy of the esophageal mucosa showed fragments of necrotic tissue with predominant lymphocyte infiltration. The patient was treated with a nothing per mouth diet, total parenteral nutrition, double-dose proton pump inhibitors and broad-spectrum antibiotics (piperacillin/tazobactam). Despite these measures, the patient underwent a progressive clinical deterioration and he died of multiple organ failure 12 days after admission.

First-in-Human Segmental Esophageal Reconstruction Using a Bioengineered Mesenchymal Stromal Cell-Seeded Implant

Introduction

Resection and reconstruction of the esophagus remains fraught with morbidity and mortality. Recently, data from a porcine reconstruction model revealed that segmental esophageal reconstruction using an autologous mesenchymal stromal cell-seeded polyurethane graft (Cellspan esophageal implant [CEI]) can facilitate esophageal regrowth and regeneration. To this end, a patient requiring a full circumferential esophageal segmental reconstruction after a complex multiorgan tumor resection was approved for an investigational treatment under the Food and Drug Administration Expanded Access Use (Investigational New Drug 17402).

Methods

Autologous adipose-derived mesenchymal stromal cells (Ad-MSCs) were isolated from the Emergency Investigational New Drug patient approximately 4 weeks before surgery from an adipose tissue biopsy specimen. The Ad-MSCs were grown and expanded under current Good Manufacturing Practice manufacturing conditions. The cells were then seeded onto a polyurethane fiber mesh scaffold (Cellspan scaffold) and cultured in a custom bioreactor to manufacture the final CEI graft. The cell-seeded scaffold was then shipped to the surgical site for surgical implantation. After removal of a tumor mass and a full circumferential 4 cm segment of the esophagus that was invaded by the tumor, the CEI was implanted by suturing the tubular CEI graft to both ends of the remaining native esophagus using end-to-end anastomosis.

Results

In this case report, we found that a clinical-grade, tissue-engineered esophageal graft can be used for segmental esophageal reconstruction in a human patient. This report reveals that the graft supports regeneration of the esophageal conduit. Histologic analysis of the tissue postmortem, 7.5 months after the implantation procedure, revealed complete luminal epithelialization and partial esophageal tissue regeneration.

Conclusions

Autologous Ad-MSC seeded onto a tubular CEI tissue-engineered graft stimulates tissue regeneration following implantation after a full circumferential esophageal resection.

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 in a patient with recent SARS-CoV-2

A 57-year-old Hispanic man with diabetes presented with dyspnoea. He had a positive SARS-CoV-2 PCR. He was intubated for severe hypoxia and treated with intermittent pressors, methylprednisolone and supportive care. He was extubated on hospital day (HD) 9 and discharged to a skilled nursing facility (SNF) on HD 18. Approximately 1 month later, he presented with melena. Endoscopy revealed two large 1.5–2 cm wide-based distal oesophageal ulcers without active bleeding. Histology showed ulcerated squamous mucosa with extensive necrosis extending to the muscularis propria and coccoid bacterial colonies with rare fungal forms suggestive of Candida. He was treated with fluconazole and pantoprazole and was discharged to a SNF. Approximately 3 weeks later, he was readmitted for complications. Repeat endoscopy demonstrated improvement and histology revealed chronic inflammation with reactive epithelial changes. Incidentally, SARS-CoV-2 PCR was positive during this visit without any respiratory symptoms.

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.

[Black esophagus and black duodenum - rare cause of an upper gastrointestinal bleeding]

We present the case of a 73-year-old female patient with acute esophageal necrosis, or black esophagus, and consecutive distal esophageal perforation. Additionally, the patient had the rare coincidence of duodenal necrosis or black duodenum. Black esophagus is usually diagnosed endoscopically and is characterized by a circular necrosis of the esophagus with abrupt normalization at the gastroesophageal junction. Black esophagus is a rare cause of symptoms of upper gastrointestinal bleeding with a mortality rate of up to 30 %. Complications include esophageal perforation and esophageal stricture formation. No causal therapy is available.

Effect of water immersion restraint stress on gastric mucosa in rats with removed salivary glands

OBJECTIVE

To explore the effect of salivary gland removal on water immersion restraint stress (WIRS)-induced gastric mucosal injury (GMI) in rats.

METHODS

Eighty male WISTAR rats were allocated into sham operation (sham) group, sham + WIRS group, salivary gland removal group, and salivary gland removal + WIRS group, with 20 rats in each group. In the sham group, skin and subcutaneous tissues were cut to expose glands. The rats in other three groups were subjected to a total salivary gland resection, and all their submandibular glands and sublingual glands and part of the parotid glands were removed, and the parotid duct was ligated. Afterwards, rats were exposed to WIRS for one and a half months and sacrificed. The severity of GMI was scored, and any histologic and ultrastructural changes were monitored.

RESULTS

There were differences in the Guth index (GMI evaluation) scores among the four groups (P=0.000), which were higher in salivary gland removal + WIRS group than those in the other three groups (all P<0.001), and were higher in the sham + WIRS group and salivary gland removal group than those in the sham group (all P=0.000). Compared with other groups, the gastric mucosa was severely injured in the salivary gland removal + WIRS group, with obvious congestion, edema, inflammatory cell infiltrate, mucosal shedding, bleeding ulcers, enlarged intercellular spaces, and damaged organelles.

CONCLUSION

Salivary gland removal aggravates WIRS-induced GMI to a certain extent.

Esophageal necrosis associated with sodium polystyrene sulfonate (Kayexalate) use

Acute esophageal necrosis is a rare cause of gastrointestinal bleeding. Endoscopically, it appears as a circumferential black-appearing mucosa affecting almost universally the mid and distal esophagus. Risk factors include low flow states, malnutrition, alcoholism, and the presence of multiple comorbidities. Prolonged exposure to gastric secretions and direct contact with corrosive agents also induce mucosal ischemia. Sodium polystyrene sulfonate use has been associated with severe gastrointestinal adverse events, including increased risk of small bowel and colonic necrosis and perforation. In susceptible individuals, sodium polystyrene sulfonate can also induce esophageal ischemia and necrosis, as illustrated in this case.

Non gastro-esophageal reflux disease related esophagitis: an overview with a histologic diagnostic approach

Several pathological conditions, other than gastro-esophageal reflux disease and its complications, can affect the esophagus. While some of these can present with unspecific lesions (i.e. ulcers and epithelial damage) and require clinico-pathological correlation for diagnosis (i.e. drug-induced esophagitis and corrosive esophagitis) other conditions show distinctive histological lesions which enable the pathologist to reach the diagnosis (i.e. some specific infectious esophagites and Crohn's disease). In this context eosinophilic esophagitis is the condition which has been increasingly studied in the last two decades, while lymphocytic esophagitis, a relatively new entity, still represents an enigma. This overview will focus on and describe histologic lesions which allow pathologists to differentiate between these conditions.

Rare complication of esophageal necrosis and perforation after fenestrated endovascular aneurysm repair

Fenestrated endovascular aneurysm repair (FEVAR) is a minimally invasive technique used to treat complex abdominal aortic aneurysms. We present the case of a 69-year-old man with a juxtarenal abdominal aortic aneurysm treated with FEVAR. The patient experienced postoperative dysphagia and sepsis. Investigations revealed a perforated esophagus due to esophageal ischemia and necrosis, leading to complete esophagectomy and subsequent esophageal reconstruction. This case highlights esophageal necrosis and perforation as a potential complication of FEVAR and serves as a reminder to have a low threshold for investigating and emergently managing this condition, which otherwise has a high mortality rate.