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Scientific letter
Black oesophagus (acute oesophageal necrosis)
Esófago negro (necrosis aguda esofágica)
Viviana Laredoa,
Corresponding author
vlaredodelatorre@gmail.com

Corresponding author.
, Mercedes Navarrob, Enrique Alfaroa, Pablo Cañamaresa, Daniel Abada, Gonzalo Hijosa, Sandra Garcíaa, Raúl Velamazána, José Manuel Blasa, Ángel Ferrándeza
a Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of an 85-year-old female patient with a history of hypertension&#44; diabetes mellitus&#44; dyslipidaemia and pulmonary embolism&#46; She had been experiencing epigastric pain for the past 3 days associated with nausea and vomiting&#46; Laboratory testing found high acute-phase reactants&#46; A plain X-ray and an abdominal CT scan were also performed and showed gastric dilatation and signs suggestive of chronic pancreatitis&#46; It was decided to extend the study by performing a gastroscopy&#46; This revealed an oesophageal surface with blackish discolouration from the proximal oesophagus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41; that did not detach with lavage&#44; suggestive of a necrotic process&#44; associated with longitudinal ulcerations and an abrupt change in the oesophageal&#8211;gastric transition &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B and C&#41;&#44; with no evidence of lesions in the stomach&#46; Multiple ulcers alternating with areas of necrosis were also present in the second duodenal segment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; Biopsies taken confirmed necrotic ischaemic changes in the duodenal mucosa&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Given the endoscopic findings&#44; another CT scan was performed&#44; this time a thoraco-abdominal CT scan&#44; which ruled out complications&#46; Treatment was started with total parenteral nutrition and intravenous omeprazole as well as empirical antifungal and antibiotic coverage with meropenem and fluconazole&#46; The patient&#39;s subsequent clinical course was satisfactory&#59; therefore&#44; following conservative management for 15 days&#44; another gastroscopy was performed&#46; It showed an oesophageal mucosa with a whitish appearance&#44; covered in fibrin&#44; with a decrease in its calibre towards the cardia&#44; which exhibited obstructive stenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41;&#46; Several sessions of endoscopic dilatation were performed successfully &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>F&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Acute oesophageal necrosis is an uncommon entity reported for the first time in 1990 by Goldenberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It primarily affects males in their fifties&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and its prevalence and incidence are low&#44; though its exact incidence and prevalence cannot be known&#44; as it is an under-diagnosed condition&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Its aetiology is multifactorial&#44; and primarily secondary to ischaemic damage in patients with cardiovascular risk factors and in a context of haemodynamic compromise or low output&#44; including sepsis&#44; heart failure&#44; acute haemorrhage and systemic inflammatory response&#46; Circulation from branches of the coeliac trunk indicates that there may be concomitant lesions in the distal oesophagus and duodenum&#46; Other factors that influence the development of lesions are abnormalities in oesophageal defensive mechanisms and massive passage of gastric contents towards the oesophagus&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In the case reported&#44; a potential flare-up of chronic pancreatitis in a patient of advanced age with cardiovascular risk factors is put forward as a possible trigger of oesophageal and duodenal lesions&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In up to 90&#37; of reported cases the initial sign is upper gastrointestinal bleeding&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> though other symptoms such as abdominal pain and vomiting may appear or the patient may be asymptomatic&#46; The condition is diagnosed by gastroscopy&#46; It is not strictly necessary to perform biopsies&#44; as the lesions are very distinctive and include a blackish oesophageal mucosa&#44; which essentially affects the distal third &#40;the least vascularised area&#41;&#44; with an abrupt stop at the gastro-oesophageal junction&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Concomitant duodenal involvement in the form of necrosis&#44; ulcers and&#47;or inflammatory changes may appear in up to 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> It is important to perform a differential diagnosis with other conditions&#44; especially if there is isolated involvement of the medial or proximal oesophagus&#59; it is necessary to rule out infectious disease&#44; melanoma&#44; <span class="elsevierStyleItalic">acanthosis nigricans</span> and ingestion of caustic substances&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> In the case presented&#44; the patient denied having ingested caustic substances&#44; and viral serology was performed and came back negative&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In general&#44; management is conservative and includes management of underlying disease and supportive measures such as fluid therapy&#44; total parenteral nutrition&#44; treatment with proton-pump inhibitors at high doses and sucralfate&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The use of empirical antibiotic treatment is controversial and is recommended if there is evidence of bacterial infection or suspected perforation&#46; In this case&#44; conservative management was pursued after complications were ruled out&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Overall mortality may be as high as 32&#37;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and is primarily associated with comorbidities as well as the seriousness of the underlying disease&#46; The most feared complication is perforation&#46; This appears in less than 7&#37; of cases and usually requires a surgical approach&#46; Treatment with an oesophageal <span class="elsevierStyleItalic">stent</span> may be considered in select cases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The most common complications include the development of stenosis &#40;in 25&#37; of cases&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>&#59; this can generally be managed with endoscopic dilatation&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Laredo V&#44; Navarro M&#44; Alfaro E&#44; Ca&#241;amares P&#44; Abad D&#44; Hijos G&#44; et al&#46; Es&#243;fago negro &#40;necrosis aguda esof&#225;gica&#41;&#46; Gastroenterol Hepatol&#46; 2020&#59;43&#58;201&#8211;202&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopic findings&#46; &#40;A&#41; Mucosa of the medial oesophagus with blackish discolouration and longitudinal ulcerations&#46; &#40;B and C&#41; Abrupt stop at the gastro-oesophageal junction&#46; &#40;D&#41; Necrosis of the second duodenal segment&#46; &#40;E&#41; Obstructive oesophageal stenosis shown on follow-up gastroscopy&#46; &#40;F&#41; Course of oesophageal stenosis following several sessions of dilatation&#46;</p>"
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