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  • 1. MR GAYATHRI THAMPATTY PGY2
  • 2. AEN (BLACK ESOPHAGUS, NECROTIZING ESOPHAGITIS) CRITERIA: •ACUTE PRESENTATION WITH ENDOSCOPIC FINDINGS CONSISTING OF A CIRCUMFERENTIAL BLACK ESOPHAGUS WITH OR WITHOUT EXUDATES. •DISTAL ESOPHAGEAL INVOLVEMENT THAT CAN EXTEND PROXIMALLY, BUT ENDS SHARPLY AT THE GASTROESOPHAGEAL BORDER. •UNIFORM HISTOLOGIC FINDINGS AFFECTING THE MUCOSA AND SUBMUCOSA AND CONSISTING OF DIFFUSE AND SEVERE NECROSIS, WITHOUT RECOGNIZABLE STRATIFIED SQUAMOUS CELLS, OCCASIONAL DERANGED MUSCLE FIBERS, HYPEREMIA AND SCATTERED THROMBOSED VESSELS WITHOUT SPECIFIC CAUSATIVE AGENTS. •OCCURRENCE IN THE ABSENCE OF CAUSTIC OR OTHER INJURIOUS AGENTS
  • 3. PATHOGENESIS • UNKNOWN. THE PRESUMED OVERALL UNDERSTANDING IS THAT OF A "TWO HIT" PHENOMENON. INITIAL EVENT ( LOW FLOW VASCULAR STATE), WHICH THEN PREDISPOSES THE ESOPHAGEAL MUCOSA TO A SEVERE TOPICAL INJURY ( REFLUX OF ACID AND PEPSIN). • ISCHEMIA LIKELY HAS A ROLE BASED UPON HISTOPATHOLOGIC AND CLINICAL DATA • IN SUPPORT OF THIS HYPOTHESIS IS THE OBSERVATION THAT TEMPORARY REDUCTION OF ESOPHAGEAL BLOOD PERFUSION CAN RESULT IN EXTENSIVE ESOPHAGEAL NECROSIS, WHICH RESOLVES RAPIDLY WHEN PERFUSION IS RESTORED • FURTHERMORE, AEN TENDS TO OCCUR IN THE DISTAL THIRD OF THE ESOPHAGUS, WHICH IS RELATIVELY HYPOVASCULAR COMPARED WITH OTHER ESOPHAGEAL SEGMENTS • FINALLY, THE NECROSIS OF THE MUCOSA AND SUBMUCOSA, MICROSCOPIC THROMBOSIS AND RAPID REGRESSION ARE SIMILAR TO
  • 4. ASSOCIATIONS • BROAD SPECTRUM ANTIBIOTICS • HYPERGLYCEMIA • UNDERLYING MALIGNANCY • HERPETIC INFECTION • GASTRIC VOLVULUS • STEVENS-JOHNSON SYNDROME • AFTER PROLONGED VOMITING FOLLOWING ALCOHOL BINGING • ALCOHOLIC LACTIC ACIDOSIS • DIABETIC KETOACIDOSIS • FOLLOWING UPPER ENDOSCOPY AND ESOPHAGEAL MANOMETRY/PHMETRY • PARAESOPHAGEAL HERNIA • ALCOHOLIC HEPATITIS • AORTIC DISSECTION [26].
  • 5. DIFFERENTIAL DIAGNOSIS • MELANOSIS — IN PATIENTS WITH UNDERLYING CHRONIC ESOPHAGITIS. SEEN IN THE DISTAL ESOPHAGUS. • PSEUDOMELANOSIS — DUE TO TISSUE DEPOSITION OF PSEUDOMELANIN, A "WEAR AND TEAR" PIGMENT DERIVED FROM LYSOSOMAL DEGRADATION. HISTOLOGICALLY IT IS SEEN AS BROWN PIGMENT WITHIN MACROPHAGES • MELANOMA — RARE. IT USUALLY ORIGINATES IN THE MID AND LOWER ESOPHAGUS • ACANTHOSIS NIGRICANS — VELVETY, VERRUCOUS, HYPERPIGMENTED SKIN AND MUCOSAL PLAQUES.CAN BE BENIGN, IT CAN ALSO BE A PARANEOPLASTIC PHENOMENON, COMMONLY ASSOCIATED WITH INTRA-ABDOMINAL MALIGNANCIES • COAL DUST AND EXOGENOUS DYE INGESTION — MOST COMMON EXOGENOUS PIGMENT TO DEPOSIT IN HUMAN BODY TISSUES • PSEUDOMEMBRANOUS ESOPHAGITIS — ASSOCIATION WITH SERIOUS SYSTEMIC ILLNESS. A THIN, YELLOW OR BLACK, CONCENTRIC MEMBRANE COATS THE DISTAL (AND LESS COMMONLY ENTIRE) ESOPHAGUS. THE MEMBRANE CAN BE DISLODGED REVEALING A FRIABLE UNDERLYING MUCOSA
  • 6. TREATMENT • ADEQUATE HYDRATION AND TREATMENT OF THE UNDERLYING ILLNESS. • AGGRESSIVE ACID SUPPRESSION, WITH INTRAVENOUS PROTON PUMP INHIBITORS. • ORAL INTAKE SHOULD BE AVOIDED FOR AT LEAST 24 HOURS AFTER WHICH SUCRALFATE SUSPENSION SHOULD BE CONSIDERED BECAUSE OF ITS THEORETICAL ROLE IN THE PREVENTION OF FURTHER ESOPHAGEAL INJURY DUE TO ITS CYTOPROTECTIVE EFFECTS AND ITS ABILITY TO BIND PEPSIN AND STIMULATE MUCUS SECRETION • NASOGASTRIC TUBES SHOULD BE WITHHELD UNLESS USED TO DECOMPRESS A GASTRIC OUTLET OBSTRUCTION OR IF PERSISTENT VOMITING IS PRESENT. • A DECISION REGARDING ANTIBIOTICS SHOULD BE MADE ON AN INDIVIDUAL BASIS, ESPECIALLY IN THE SETTING OF PATIENTS WHO ARE CRITICALLY ILL OR APPEAR TO BE SEPTIC. • NEED FOR REPEAT ENDOSCOPY SHOULD BE GUIDED BY THE PATIENT'S CLINICAL COURSE. • AS A GENERAL RULE, THE ENDOSCOPIC FINDINGS REVERT TO NORMAL FAIRLY RAPIDLY. • IT IS IMPORTANT TO MONITOR FOR COMPLICATIONS SUCH AS ESOPHAGEAL STENOSIS, WHICH MAY PRESENT AS DYSPHAGIA, AND MAY REQUIRE REPEAT ENDOSCOPY FOR DIAGNOSIS AND THERAPY.
  • 7. PROGNOSIS • HIGH MORTALITY RELATED TO THE UNDERLYING ILLNESSES IN PATIENTS WITH ACUTE ESOPHAGEAL NECROSIS (AEN) (AND THE LIMITED NUMBER OF REPORTED CASES) OBSCURES A DETAILED UNDERSTANDING OF ITS NATURAL HISTORY.
  • 8. THANK YOU

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