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[EsoTODAY 044 - Black esophagus. Acute esophageal necrosis (AEN)]

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Black esophagus or acute esophageal necrosis (AEN) is a striking medical condition characterized by circumferential black appearing esophageal mucosa affecting various lengths of the organ with nearly universal involvement of the distal esophagus and abrupt transition at the gastroesophageal junction (Dig Dis Sci. 2015). The etiological factor involved seems to be ischemic injury caused by arteriolosclerosis, arterial thrombosis, or aortic dissection.

Acute esophageal necrosis (= black esophagus)는 중증 전신 질환을 가진 환자에서 아마도 허혈성으로 발생하는 심한 급성 궤사성 질환입니다. 이름처럼 식도가 까맣게 보입니다. 2015년 international case series가 발표된 바 있습니다 (Dig Dis Sci. 2015).

"AEN is more common in geriatric males and characteristically (88 %) presents with signs of upper gastrointestinal hemorrhage. Risk factors include alcohol abuse, hypertension, diabetes mellitus, dyslipidemia, chronic kidney disease, malnourishment, and vascular disease. Hypoalbuminemia was universal, while anemia, renal insufficiency, and hyperglycemia were seen in nearly 90 % of the patients. Endoscopically, distal esophageal involvement with various proximal extension and sharp demarcation at the GE junction was seen in all patients. Duodenal pathology was seen in 50 % of the cases. Causes of AEN were largely multifactorial with all patients affected by a combination of ischemic insult, compromised mucosal defenses, and corrosive reflux injury of gastric contents. Treatment with acid suppression and correction of underlying medical conditions was implemented in all patients. Esophageal stricture formation was seen in 25 % of the patients and was associated with concurrent duodenal pathology. Mortality was 12.5 % and unrelated to AEN."

Dig Dis Sci. 2015

워낙 충격적인 모양새인지라 학회 포스터로 발표되는 예가 많습니다.

Acute esophageal necrosis (AEN), also known as "black esophagus" is characterized by a striking circumferential black appearance of esophageal mucosa on endoscop. AEN is a rare and is almost invariably associated with severe clinical conditions and serious comorbidities. (KDDW 2017. 가톨릭대)

Black esophagus (KDDW 2017. 영남대)


[FAQ]

[2018-7-4. 애독자 편지]

보내주신black esophagus 증례들을 잘 보았습니다. 최근 한 증례를 경험한 적이 있어 메일 드립니다. 환자는 췌장암 십이지장 침윤으로 stent 삽입을 하는 내시경 도중 진단된 경우입니다. 이후 추적 내시경을 하였는데 상당히 호전된 상태였습니다. 저로서는 black esophagus는 처음 경험해 본 증례였습니다.

당시 주치의 선생님이 경과기록에 문헌고찰을 잘 기록해 놓아 많은 도움이 되었습니다.

Black esophagus: Acute esophageal necrosis syndrome. Grigoriy E Gurvits, World J Gastroenterol 2010 July 14; 16(26): 3219-3225

AEN is thought to arise from a combination of an ischemic insult to the esophagus, impaired mucosal barrier systems, and a backflow injury from chemical contents of gastric secretions. Male sex, older age, chronic medical conditions, including diabetes mellitus, hematologic and solid organ malignancy, malnutrition, renal insufficiency, cardiovascular compromise, trauma, and thromboembolic phenomena place a patient at a higher risk for developing AEN.

ETIOLOGY: A combination of
1) tissue hypoperfusion
2) impaired local defense barriers
3) massive influx of gastric contents

Charicteristic relative sparing of the gastric mucosa can be explained by the acidic impact on the ischemic esophageal and duodenal surface, as well as typically rapid repair of the injured gastric mucosa (within hours) compared to the esophagus (may take days). The duodenal bulb ulcers and edema may result in gastric outlet obstruction that, in turn, potentiates the development of mucosal necrosis of the distal esophagus. Back flow injury from the acid, pepsin, and other gastric contents is augmented by the increased transient lower esophageal sphincter relaxation, decreased resting lower esophageal pressure, prolonged recumbence, decreased esophageal peristalsis, and increased gastroesophageal reflux.


[References]

1) EndoTODAY 장기별 증례 토의

2) EsoTODAY - 식도 질환 증례 토의

© 일원내시경교실 바른내시경연구소 이준행. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.