# Black esophagus: complete esophageal necrosis with lower esophageal perforation.

Lucile Héroin, Pierre-Yves Christmann, Francois Habersetzer, Pierre Mayer

► To cite this version:

Lucile Héroin, Pierre-Yves Christmann, Francois Habersetzer, Pierre Mayer. Black esophagus: complete esophageal necrosis with lower esophageal perforation.. Endoscopy, 2024, 56 (S 01), 10.1055/a-2226-0404. hal-04524171

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Submitted on 2 Apr 2024

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# Black esophagus: complete esophageal necrosis with lower esophageal perforation.

Lucile Héroin, Pierre-Yves Christmann, Francois Habersetzer, Pierre Mayer

► To cite this version:

Lucile Héroin, Pierre-Yves Christmann, Francois Habersetzer, Pierre Mayer. Black esophagus: complete esophageal necrosis with lower esophageal perforation.. Endoscopy, 2024, 56 (S 01), 10.1055/a-2226-0404. hal-04524171

HAL Id: hal-04524171

https://hal.science/hal-04524171v1

Submitted on 2 Apr 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_2.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
<figure><img src="image_2.png" /></figure>

# Black esophagus: complete esophageal necrosis with lower esophageal perforation

OPEN
ACCESS

Black esophagus or acute esophageal necrosis is a rare condition, mainly reported as case reports in the literature [1]. Its pathogenesis seems to be multifactorial, with ischemia appearing to be the most common etiology in patients with cardiovascular risk factors and chronic medical conditions [2]. Diagnosis can be suggested by computed tomography (CT) findings but is based on upper gastrointestinal endoscopy. Mortality is high (30%). Treatment is conservative in most cases (75.4%), but endoscopic or surgical interventions can be required (25.6%) [3].

We report the case of a 72-year-old man, with no medical history other than diabetes, which was managed with biguanides, who was admitted to the emergency room because of urinary tract infection with sepsis. He was rapidly transferred to intensive care because of hemodynamic instability.

Biology showed acute inflammation with leukocytosis and hyperlactatemia, and acute renal failure. Blood cultures were positive for Corynebacterium confusum and Streptococcus sanguinis. Aspergillus antigen was also positive. The CT scan with injection and ingestion showed a circumferential hydroaeric infiltration of the distal esophagus, with a suspected esophageal rupture, a left basal pneumonitis, and bilateral pleural effusion (► Fig. 1, ► Video 1).

Upper gastrointestinal endoscopy was performed and showed complete esophageal necrosis, from the upper esophagus to the gastroesophageal junction (► Fig. 2), where the necrosis abruptly stopped. The stomach was unharmed. Opacification showed a perforation in the lower esophagus (► Fig. 3).

The patient had expressed his opposition to intensive care when he was alive. The treatment therefore consisted solely of symptomatic therapy, and the patient died within a few hours.

Endoscopy_UCTN Code_CCL_1AB_2AC_3AH

## Conflict of Interest

The authors declare that they have no conflict of interest.

## The authors

Lucile Héroin¹,²*, Pierre-Yves Christmann¹,², François Habersetzer¹,²,³, Pierre Mayer¹,²*

1. Department of Hepatology and Gastroenterology, Pôle Hépato-digestif, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (HUS), Strasbourg, France

2. Digestive Endoscopy, IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France

3. Inserm U1110, Institute for Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Faculty of Medicine, Strasbourg, France

<figure><img src="image_3.png" /><figcaption>► **Video 1** Complete esophageal necrosis with lower esophageal perforation.</figcaption></figure>

<figure><img src="image_4.png" /><figcaption>► **Fig. 1** Computed tomography scan with injection and ingestion, showing a circumferential hydroaeric infiltration of the distal esophagus, with a suspected esophageal rupture (blue circle)</figcaption></figure>

<figure><img src="image_5.png" /><figcaption>► **Fig. 2** Complete esophageal necrosis.</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>► **Fig. 3** Opacification showing the lower esophageal perforation (arrow).</figcaption></figure>
<figure><img src="image_3.png" /></figure>

# Black esophagus: complete esophageal necrosis with lower esophageal perforation

OPEN
ACCESS

Black esophagus or acute esophageal necrosis is a rare condition, mainly reported as case reports in the literature [1]. Its pathogenesis seems to be multifactorial, with ischemia appearing to be the most common etiology in patients with cardiovascular risk factors and chronic medical conditions [2]. Diagnosis can be suggested by computed tomography (CT) findings but is based on upper gastrointestinal endoscopy. Mortality is high (30%). Treatment is conservative in most cases (75.4%), but endoscopic or surgical interventions can be required (25.6%) [3].

We report the case of a 72-year-old man, with no medical history other than diabetes, which was managed with biguanides, who was admitted to the emergency room because of urinary tract infection with sepsis. He was rapidly transferred to intensive care because of hemodynamic instability.

Biology showed acute inflammation with leukocytosis and hyperlactatemia, and acute renal failure. Blood cultures were positive for Corynebacterium confusum and Streptococcus sanguinis. Aspergillus antigen was also positive. The CT scan with injection and ingestion showed a circumferential hydroaeric infiltration of the distal esophagus, with a suspected esophageal rupture, a left basal pneumonitis, and bilateral pleural effusion (► Fig. 1, ► Video 1).

Upper gastrointestinal endoscopy was performed and showed complete esophageal necrosis, from the upper esophagus to the gastroesophageal junction (► Fig. 2), where the necrosis abruptly stopped. The stomach was unharmed. Opacification showed a perforation in the lower esophagus (► Fig. 3).

The patient had expressed his opposition to intensive care when he was alive. The treatment therefore consisted solely of symptomatic therapy, and the patient died within a few hours.

Endoscopy_UCTN Code_CCL_1AB_2AC_3AH

## Conflict of Interest

The authors declare that they have no conflict of interest.

## The authors

Lucile Héroin¹,²*, Pierre-Yves Christmann¹,², François Habersetzer¹,²,³, Pierre Mayer¹,²*

1. Department of Hepatology and Gastroenterology, Pôle Hépato-digestif, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (HUS), Strasbourg, France

2. Digestive Endoscopy, IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France

3. Inserm U1110, Institute for Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Faculty of Medicine, Strasbourg, France

<figure><img src="image_4.png" /><figcaption>► **Video 1** Complete esophageal necrosis with lower esophageal perforation.</figcaption></figure>

<figure><img src="image_5.png" /><figcaption>► **Fig. 1** Computed tomography scan with injection and ingestion, showing a circumferential hydroaeric infiltration of the distal esophagus, with a suspected esophageal rupture (blue circle)</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>► **Fig. 2** Complete esophageal necrosis.</figcaption></figure>

<figure><img src="image_7.png" /><figcaption>► **Fig. 3** Opacification showing the lower esophageal perforation (arrow).</figcaption></figure>
<figure><img src="image_7.png" /></figure>

## Corresponding author

**Lucile Héroin, MD**

Service d'Hépato-gastroentérologie,
Hôpitaux Universitaires de Strasbourg,
Nouvel Hôpital Civil, Quai Louis Pasteur 1,
67000 Strasbourg, France
lucileheroin@gmail.com

## References

[1] Dias E, Santos-Antunes J, Macedo G. Diagnosis and management of acute esophageal necrosis. Ann Gastroenterol 2019; 32: 529–540. doi:10.20524/aog.2019.0418

[2] Gurvits GE. Black esophagus: acute esophageal necrosis syndrome. World J Gastroenterol 2010; 16: 3219–3225. doi:10.3748/wjg.v16.i26.3219

[3] Schizas D, Theochari NA, Mylonas KS et al. Acute esophageal necrosis: a systematic review and pooled analysis. World J Gastrointest Surg 2020; 12: 104–115. doi:10.4240/wjgs.v12.i3.104

## Bibliography

Endoscopy 2024; 56: E53–E54

DOI 10.1055/a-2226-0404

ISSN 0013-726X

© 2024. The Author(s).

This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited.

(https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG, Rüdigerstraße 14,
70469 Stuttgart, Germany

<figure><img src="image_8.png" /></figure>

<figure><img src="image_9.png" /></figure>

## ENDOSCOPY E-VIDEOS
https://eref.thieme.de/e-videos

<figure><img src="image_10.png" /></figure>

E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).

This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
<figure><img src="image_8.png" /></figure>

## Corresponding author

**Lucile Héroin, MD**

Service d'Hépato-gastroentérologie,
Hôpitaux Universitaires de Strasbourg,
Nouvel Hôpital Civil, Quai Louis Pasteur 1,
67000 Strasbourg, France
lucileheroin@gmail.com

## References

[1] Dias E, Santos-Antunes J, Macedo G. Diagnosis and management of acute esophageal necrosis. Ann Gastroenterol 2019; 32: 529–540. doi:10.20524/aog.2019.0418

[2] Gurvits GE. Black esophagus: acute esophageal necrosis syndrome. World J Gastroenterol 2010; 16: 3219–3225. doi:10.3748/wjg.v16.i26.3219

[3] Schizas D, Theochari NA, Mylonas KS et al. Acute esophageal necrosis: a systematic review and pooled analysis. World J Gastrointest Surg 2020; 12: 104–115. doi:10.4240/wjgs.v12.i3.104

## Bibliography

Endoscopy 2024; 56: E53–E54

DOI 10.1055/a-2226-0404

ISSN 0013-726X

© 2024. The Author(s).

This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited.

(https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG, Rüdigerstraße 14,
70469 Stuttgart, Germany

<figure><img src="image_9.png" /></figure>

<figure><img src="image_10.png" /></figure>

## ENDOSCOPY E-VIDEOS
https://eref.thieme.de/e-videos

<figure><img src="image_11.png" /></figure>

E-Videos is an open access online section of the journal *Endoscopy*, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).

This section has its own submission website at https://mc.manuscriptcentral.com/e-videos