Clinical features of acute esophageal mucosal lesions and reflux esophagitis Los Angeles classification grade D: A retrospective study

BACKGROUND Acute esophageal mucosal lesions(AEMLs)are an underrecognized and largely unexplored disease.Endoscopic findings are similar,and a higher percentage of AEML could be misdiagnosed as reflux esophagitis Los Angeles classification grade D(RE-D).These diseases could have different pathologies and require different treatments.AIM To compare AEML and RE-D to confirm that the two diseases are different from each other and to clarify the clinical features of AEML.METHODS We selected emergency endoscopic cases of upper gastrointestinal bleeding with circumferential esophageal mucosal injury and classified them into AEML and RE-D groups according to the mucosal injury’s shape on the oral side.We examined patient background,blood sampling data,comorbidities at onset,endoscopic characteristics,and outcomes in each group.RESULTS Among the emergency cases,the AEML and RE-D groups had 105(3.1%)and 48(1.4%)cases,respectively.Multiple variables exhibited significantly different results,indicating that these two diseases are distinct.The clinical features of AEML consisted of more comorbidities[risk ratio(RR):3.10;95%confidence interval(CI):1.68–5.71;P<0.001]and less endoscopic hemostasis compared with RE-D(RR:0.25;95%CI:0.10–0.63;P<0.001).Mortality during hospitalization was higher in the AEML group(RR:3.43;95%CI:0.82–14.40;P=0.094),and stenosis developed only in the AEML group.CONCLUSION AEML and RE-D were clearly distinct diseases with different clinical features.AEML may be more common than assumed,and the potential for its presence should be taken into account in cases of upper gastrointestinal bleeding with comorbidities.

Acute upper gastrointestinal bleeding due to portal hypertension in a patient with primary myelofibrosis:A case report

BACKGROUND Acute upper gastrointestinal bleeding is a common medical emergency that has a 10%hospital mortality rate.According to the etiology,this disease can be divided into acute varicose veins and nonvaricose veins.Bleeding from esophageal varices is a life-threatening complication of portal hypertension.Portal hypertension is a clinical syndrome defined as a portal venous pressure that exceeds 10 mmHg.Cirrhosis is the most common cause of portal hypertension,and thrombosis of the portal system not associated with liver cirrhosis is the second most common cause of portal hypertension in the Western world.Primary myeloproliferative disorders are the main cause of portal venous thrombosis,and somatic mutations in the Janus kinase 2 gene(JAK2 V617F)can be found in approximately 90% of polycythemia vera,50% of essential thrombocyrosis and 50% of primary myelofibrosis.CASE SUMMARY We present a rare case of primary myelofibrosis with gastrointestinal bleeding as the primary manifestation that presented as portal-superior-splenic mesenteric vein thrombosis.Peripheral blood tests revealed the presence of the JAK2 V617F mutation.Bone marrow biopsy ultimately confirmed the diagnosis of myelofibrosis(MF-2 grade).CONCLUSION In patients with acute esophageal variceal bleeding due to portal hypertension and vein thrombosis without cirrhosis,the possibility of myeloproliferative neoplasms should be considered,and the JAK2 mutation test should be performed.

Clinical Evaluation of Yangyin Qingre Shengji Decoction(养阴清热生肌汤)in Preventing and Treating Acute Radiation Esophagitis

Objective:To explore the prevention and treatment effect of Yangyin Qingre Shengji Decoction(养阴清热生肌汤)on acute radiation esophagitis.Methods:From May 2020 to February 2021,60 patients with malignant tumor who underwent radiotherapy were selected as the research objects.They were divided into two groups by odd and even number drawing,30 cases in the control group and 30 cases in the observation group.The control group took mixed solution orally,while the observation group took Yangyin Qingre Shengji Decoction.The clinical effects,occurrence time,duration,grading of acute radiation esophagitis and TCM syndrome scores of dry mouth and constipation were compared between the two groups.Results:The effective rate of the observation group was significantly higher than that of the control group(P<0.05);Compared with the control group,the time of acute radiation esophagitis was prolonged and the duration of symptoms was shortened in the observation group(P<0.05);The incidence of above gradeⅡin the observation group was significantly lower than that in the control group,and the incidence of below gradeⅠwas significantly higher than that in the control group(P<0.05);There was no significant difference in the scores of dry mouth and constipation between the two groups before treatment(P>0.05),the scores of the two groups were decreased after treatment,and the observation group was lower than the control group(P<0.05).Conclusion:Yangyin Qingre Shengji Decoction(养阴清热生肌汤)has a positive effect on prevention and treatment of acute radiation esophagitis in patients with malignant tumor undergoing radiotherapy,which can be popularized.

Black esophagus: Acute esophageal necrosis syndrome

Acute esophageal necrosis (AEN), commonly referred to as "black esophagus", is a rare clinical entity arising from a combination of ischemic insult seen in hemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophago-gastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. AEN may arise in the setting of multiorgan dysfunction, hypoperfusion, vasculopathy, sepsis, diabetic ketoacidosis, alcohol intoxication, gastric volvulus, traumatic transection of the thoracic aorta, thromboembolic phenomena, and malignancy. Clinical presentation is remarkable for upper gastrointestinal bleeding. Notable symptoms may include epigastric/abdominal pain, vomiting, dysphagia, fever, nausea, and syncope. Associated laboratory f indings may reflect anemia and leukocytosis. The hallmark of this syndrome is the development of diffuse circumferential black mucosal discoloration in the distal esophagus that may extend proximally to involve variable length of the organ. Classic "black esophagus" abruptly stops at the gastroesophageal junction. Biopsy is recommended but not required for the diagnosis. Histologically, necrotic debris, absence of viable squamous epithelium, and necrosis of esophageal mucosa, with possible involvement of submucosa and muscularis propria, are present. Classif ication of the disease spectrumis best described by a staging system. Treatment is directed at correcting coexisting clinical conditions, restoring hemodynamic stability, nil-per-os restriction, supportive red blood cell transfusion, and intravenous acid suppression with proton pump inhibitors. Complications include perforation with mediastinal infection/abscess, esophageal stricture and stenosis, superinfection, and death. A high mortality of 32% seen in the setting of AEN syndrome is usually related to the underlying medical co-morbidities and diseases.

Acute esophageal necrosis as a complication of diabetic ketoacidosis:A case report

BACKGROUND Acute esophageal necrosis(AEN)is a rare condition that has been associated with low volume states,microvascular disease,gastrointestinal(GI)mucosal damage,and impaired GI motility.It has been linked in case reports with diabetic ketoacidosis(DKA)and is commonly associated with GI bleeding(GIB).CASE SUMMARY We report a case of endoscopy confirmed AEN as a complication of DKA in a 63-year-old Caucasian male without any overt GIB and a chief complaint of epigastric pain.Interestingly,there was no apparent trigger for DKA other than a newly started ketogenic diet two days prior to symptom onset.A possible potentiating factor for AEN beyond DKA is the recent start of a Glucagon-like peptide-1 receptor agonist(GLP-1 RA),though they have not been previously connected to DKA or AEN.The patient was subsequently treated with high dose proton pump inhibitors,GLP-1 RA was discontinued,and an insulin regimen was instituted.The patient’s symptoms improved over the course of several weeks following discharge and repeat endoscopy showed well healing esophageal mucosa.CONCLUSION This report highlights AEN in the absence of overt GIB,emphasizing the importance of early consideration of EGD.

Acute esophageal necrosis: A systematic review and pooled analysis

BACKGROUND Acute esophageal necrosis(AEN)is a rare entity with multifactorial etiology,usually presenting with signs of upper gastrointestinal bleeding.AIM To systematically review all available data on demographics,clinical features,outcomes and management of this medical condition.METHODS A systematic literature search was performed with respect to the PRISMA statement(end-of-search date:October 24,2018).Data on the study design,interventions,participants and outcomes were extracted by two independent reviewers.RESULTS Seventy-nine studies were included in this review.Overall,114 patients with AEN were identified,of whom 83 were males and 31 females.Mean patient age was 62.1±16.1.The most common presenting symptoms were melena,hematemesis or other manifestations of gastric bleeding(85%).The lower esophagus was most commonly involved(92.9%).The most widely implemented treatment modality was conservative treatment(75.4%),while surgical or endoscopic intervention was required in 24.6%of the cases.Mean overall followup was 66.2±101.8 d.Overall 29.9%of patients died either during the initial hospital stay or during the follow-up period.Gastrointestinal symptoms on presentation[Odds ratio 3.50(1.09-11.30),P=0.03]and need for surgical or endoscopic treatment[surgical:Odds ratio 1.25(1.03-1.51),P=0.02;endoscopic:Odds ratio 1.4(1.17-1.66),P<0.01]were associated with increased odds of complications.A sub-analysis separating early versus late cases(after 2006)revealed a significantly increased frequency of surgical or endoscopic intervention(9.7%vs 30.1%respectively,P=0.04)CONCLUSION AEN is a rare condition with controversial pathogenesis and unclear optimal management.Although the frequency of surgical and endoscopic intervention has increased in recent years,outcomes have remained the same.Therefore,further research work is needed to better understand how to best treat this potentially lethal disease.

Effect of Compound Zhuye Shigao Granule(复方竹叶石膏颗粒)on Acute Radiation-Induced Esophagitis in Cancer Patients:A Randomized Controlled Trial

Objective： To observe the efficacy and safety of the Chinese medicine（CM） Compound Zhuye Shigao Granule（复方竹叶石膏颗粒, CZSG） on acute radiation-induced esophagitis（ARIE） in cancer patients. Methods： In a blinded, randomized, Kangfuxin Solution（康复新液, KFX）-controlled, single-centre clinical trial, 120 patients with lung, esophagus or mediastinal cancer were prospectively enrolled and assigned to the treatment group（60 cases） and control group（60 cases） by the random number table method. All patients received concurrent or sequential radiotherapy（2 Gy per day, 5 times per week, for 4 weeks） and were treated for 4 weeks since the radiation therapy. Patients in the treatment group were given 12 mg CZSG orally, thrice daily, while patients in the control group were given 10 m L KFX orally, thrice daily. The major indicators were observed, including the incidence and grade of esophagitis, time of occurrence and duration. Minor indicators were changes of CM symptoms, weight and Karnofsky Performance Status（KPS） Scale during 4 weeks from the beginning, recorded once a week. Blood routine examination and hepatorenal function were detected at the 2nd and 4th weeks. Results： The incidence and grade of ARIE were significantly decreased in the treatment group compared with the control group（P〈0.05）. CZSG appeared to significantly delay the time of ARIE occurrence and reduce the duration compared with KFX（P〈0.05）. The scores of CM symptoms, KPS and weight were improved significantly in the treatment group compared with the control group（P〈0.05）. There were no blood routine and hepatorenal function abnormal or obvious side-effects in both groups. Hemoglobin was improved and neutrophil and interleukin 6 were decreased in both groups after 4-week treatment compared with before treatment（P〈0.05）, and there was no significant difference between the two groups（P〉0.05）. Conclusions： CZSG can decrease the incidence and grade of ARIE, delay the time of occurrence, reduce duration and alleviate the damage of ARIE. It is safe and effective in the prevention and cure of ARIE.

Comparison of emergency endoscopic variceal ligation plus octride or octride alone for acute esophageal variceal bleeding

Background Octride was the main method for the treatment of esophageal variceal bleeding （EVB）. The aim of this study was to compare the cost-effect and safety between esophageal variceal ligation （EVL） plus octride and octride alone in acute esophageal bleeding. Methods A total of 101 cirrhotic patients with EVB were involved in this study and received emergency EVL ± octride （EVL group） or only octride therapy randomly. The cost, efficacy and safety were analyzed and compared between the two groups. Results Among 51 patients in EVL group, 5 （10%） patients failed. Among 50 patients in the octride treatment group, 13 patients （26%） failed. The difference was significant （P 〈0.05）. The average blood transfusion volume was （2.4±2.2） units in the EVL group and （6.4±3.4） units in the octride treatment group （P〈0.05）. Hospital stay was （7.4±1.3） days in the EVL group and （11.4±3.3） days in the octride treatment group （P 〈0.05）. The average hospital cost was （10 983±1147） yuan in the EVL group and （13 921 ±2107） yuan in the octride treatment group （P 〈0.05）. Conclusion Emergency endoscopic ligation plus octride is superior to octride alone in the treatment of acute EVB with lower cost and higher efficacy with enough safety.