a biopsy was not obtained . The patient was kept nothing-by-mouth and started on intravenous proton pump inhibitor and sucralfate and resuscitated with blood transfusions and intravenous fluids . A chest computerized tomography scan revealed no acute lung process , no esophageal perforation , or free air but with thickening of the distal esophagus , consistent with the known AEN . His hemoglobin remained stable throughout his hospital stay and he was ultimately transitioned to oral feeds and discharged home .
DISCUSSION
AEN , also known as black esophagus or Gurvits syndrome , is a rare clinical entity that arises from ischemic insult , corrosive injury , gastric outlet obstruction , decreased functional gastrointestinal barrier , and altered repair mechanisms in malnutrition or debilitated physical states . However , the etiology is often multifactorial . 1 At endoscopy , AEN is characterized by diffuse circumferential black mucosal discoloration in the esophagus with an abrupt cut-off at the gastroesophageal junction . Histological findings include necrotic debris , absence of viable squamous epithelium , and necrosis of the esophageal mucosa with involvement of the submucosa and muscularis propria . Biopsy is supportive but not mandatory to make the diagnosis . 1
Risk factors of AEN include male sex , multiorgan dysfunction , hypoperfusion , vasculopathy , sepsis , diabetic ketoacidosis , renal disease , cardiovascular disease , alcohol intoxication , gastric volvulus , traumatic transection of the thoracic aorta , thromboembolic phenomenon , and malignancy . 1 , 2 In general , a patient suffering from AEN typically has chronic predisposing risk factors with an acute triggering event . 1 Patients usually present with upper gastrointestinal bleeding , other symptoms including abdominal pain , vomiting , dysphagia , and change in mental status . Complications from AEN include strictures , stenosis , abscesses , tracheoesophageal fistula , and perforation of the esophagus . 3 Management strategies are aimed at hemodynamic resuscitation , initiating anti-acid therapy , and management of coexisting conditions . 4 Due to the increased risk of esophageal perforation , endoscopic management of areas of bleeding is usually limited to local injection of epinephrine . 1 In-hospital mortality in AEN can be as high as 30-35 %. 4 , 5
Several cases have been reported of patients developing AEN in the context of severe SARS-CoV-2 infection , usually with associated marked hemodynamic instability . 6 , 7 Our patient ’ s complaint of fatigue may have been due to a mild SARS- CoV-2 infection , but otherwise , he had no other symptoms related to a SARS-CoV-2 infection and had no associated hemodynamic instability , yet he developed AEN . Several mechanisms can explain AEN in general in SARS-CoV-2 patients . Patients with severe SARS-CoV-2 can have associated hemodynamic instability , which predisposes them to acute esophageal injury . SARS-CoV-2 is thought to enter cells through angiotensin-converting enzyme-2 ( ACE2 ) receptors and cause direct damage and a local inflammatory response at the site of infection . In addition to ACE2 receptors being located on respiratory mucosa , they are also located throughout the gastrointestinal tract , including the esophagus . 5 – 8 It is well documented that SARS-CoV-2 RNA can be recovered in stool samples , and the viral nucleoside protein has been isolated in the gastrointestinal tract . 9 SARS- CoV-2 infection causes a prothrombotic
state . The pathophysiology behind this prothrombotic state in SARS-CoV-2 is unknown but thought to be multifactorial , with known local coagulopathy at the site of initial viral infection , more commonly and well documented in the lungs . 10 Given all of these possible mechanisms , patients with SARS-CoV-2 infection could likely be more predisposed to having AEN , especially if the virus enters through and infects the esophagus and causes a local coagulopathy and inflammatory reaction at that site . Our patient had known risk factors for AEN , including cardiovascular and renal disease . The exact cause of our patient ' s AEN is unknown , and likely multifactorial , but may include his active SARS-CoV-2 infection . Patients with AEN generally have chronic predisposing conditions , with an acute precipitating event resulting in AEN . 1
CONCLUSION
Like most suffering from AEN , our patient had multiple medical conditions that may have predisposed him to AEN . We propose that the acute precipitating event for his AEN was a direct result of the SARS-CoV-2 virus . Our patient ’ s SAR- CoV-2 infection appeared mild , with only a complaint of fatigue and no significant pulmonary symptoms , abnormal pulmonary imaging , or deranged hemodynamics . It is possible that in this patient , the SARS-CoV-2 virus , entering through esophageal ACE2 receptors , caused local esophageal coagulopathy and inflammatory reaction as one of the many possible mechanisms for his AEN . Our case highlights the importance of clinicians being aware that the SARS-CoV-2 virus is a cause of gastrointestinal bleeding , in particular AEN , and may perhaps occur even in non-critically ill patients .
REFERENCES
1 . Dias E , Santos-Antunes J , Macedo G . Diagnosis and management of acute esophageal necrosis . Ann Gastroenterol . 2019 ; 32 ( 6 ): 529-540 . doi : 10.20524 / aog . 2019.0418
2 . Rehman O , Jaferi U , Padda I ,
Khehra N , Atwal H , Parmar M . Epidemiology , pathogenesis , and clinical manifestations of acute esophageal necrosis in adults . Cureus . 2021 ; 13 ( 7 ): e16618 . doi : 10.7759 / cureus . 16618
3 . Schizas D , Theochari N , Mylonas K , et al . Acute esophageal necrosis : A systematic review and pooled analysis . World J Gastrointest Surg . 2020 ; 12 ( 3 ): 104-115 . doi : 10.4240 / wjgs . v12 . i3.104
4 . Gurvits G . Black esophagus : Diagnostic associations and management
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