Black oesophagus Meng-Chiung Lin , Heng-Cheng Chu

QJM Advance Access published May 13, 2015
Black oesophagus
Meng-Chiung Lin1,2, Heng-Cheng Chu 1, Peng-Jen Chen 1
1
Division of Gastroenterology, Department of Internal Medicine , Tri-Service
General Hospital, National Defense Medical Center, Taipei, Taiwan
2
Department of Internal Medicine, Taichiung Armed Forces General Hospital,
Taichiung, Taiwan
Corresponding author:
Peng-Jen Chen
Tel.: +886 2 87923311#12983; Fax: +886 2 87927248;
E-mail: [email protected]
There are no potential conflicts of interest, including full disclosure of any financial
arrangements between any authors. The authors transfer all copyright ownership of
the above manuscript to in the event the work is published.
© The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians.
All rights reserved. For Permissions, please email: [email protected]
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Division of Gastroenterology, Department of Internal Medicine, Tri-Service General
Hospital, National Defense Medical Center, N 325, sec 2, Cheng-Gong Rd, Neihu 114,
Taipei, Taiwan
A 70-year old male with medical history of hypertensive cardiovascular disease ,
diabetes mellitus (DM) with chronic renal insufficiency, atrial fibrillation (Af), sick
sinus syndrome (SSS), and adenocarcinoma of prostate, presented with a 2-day
history of melena, and hematemesis. On examination, he was afebrile and
hemodynamically stable. Excepts for slight tachycardia (HR:110 beats/min) and
epigastric tendereness, no other abnormalities were noted. Laboratory analysis
revealed hemoglobin of 14.5 g/dL, and creatinine of 1.7mg/dL, respectively. The fecal
occult blood test is positive. Esophagogastroduodenoscopy (EGD) revealed diffuse
as well as sharp demarcation at the gastroesophageal (GE) junction, which were
suggestive of acute necrotizing esophagus (Fig. 1a). However, tissue sampling was
not performed due to multiple comorbidity and potential perforation.
After combination treatment with oral sucralfate and proton-pump inhibitor (PPI)
for two weeks, a follow-up EGD showed complete resolution of previous black
mucosa (Fig. 1b).
Acute esophageal necrosis (AEN), also known as “black oesophagus” or “acute
necrotizing esophagitis ”, is a rare clinical scenario with hemorrhagic manifestations
mostly1. The exact pathophysiology of AEN still remain unclear. However, it is
believed to be multifactorial. It is generally seen in individual with
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black pigmentation with extensive ulcerative mucosa in the mid-to-distal esophagus
ischemia-associated phenomena, such as unstable hemodynamic compromise , back
flow injury due to transient gastric outlet obstruction, and cardiovascular event, and
excessive alcohol abuse2. Generally, risk factors of ANE are male, the elderly, poor
general conditions (including malnutrition, multiple comorbidity), excessive alcohol
abuse and immunocompromised state3. Opportunistic cytomegalovirus and herpes
simplex virus infections were also reported to be the possible etiologies4,5
Clinical history of caustic ingestion or previous foreign body associated injury
should be first taken and excluded. Other diagnostic considerations to exclude include
Except for intravenous PPI, no standardized treatment therapy is recommended for
treating AEN. Removal of the identified etiology, maintain perfusion and supportive
care are best strategies. Surgery is only preserved for those with severe complications.
As Ben Soussan E reported in a prospective 1-year study, the mortality rate of AEN is
50%(4/8). However, all the mortality cases were attributed to coexist illness instead of
the disease itself.６
In conclusion, we present a case of AEN. Our patient’s gender, advanced age, habit
of alcohol abuse, and debilitating medical conditions (HCVD, diabetes, Af, maligancy)
fit well with risks factors of AEN. Now, he remains symptom free and recovery from
endoscopy.
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acanthosis nigricans, pseudomelanosis, melanosis and malignant melanoma.
Reference
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in the dark. Dis Esophagus 2000;13:311-313.
2. Endo T, Sakamoto J, Sato K, et al. Acute esophageal necrosis caused by
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James G. Robilotti. Acute esophageal necrosis: a rare syndrome. J
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esophagus associated with herpes esophagitis. Gastrointest Endosc 1999; 49:
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acute necrotizing esophagitis. Endoscopy. 2001 Aug;33(8):735.
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Acute esophageal necrosis: a 1-year prospective study. Gastrointest Endosc
2002; 56: 213-217.
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4. Cattan P, Cuillerier E, Cellier C, Carnot F, Landi B, Dusolel A, et al. Black
Figure 1. Endoscopic views of esophageal findings. (a, b), a) AEN is characterized by
a circumferential & black-brownish appearing of the esophageal mucosa with abrupt
ending at the GE junction, b) recovery of AEN with healing ulceration in distal
esophagus.
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71x49mm (300 x 300 DPI)
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70x49mm (300 x 300 DPI)