Three cases of an unusual cause of haematemesis: black oesophagus.

Black oesophagus, also termed acute oesophageal necrosis or Gurvits syndrome, is an uncommon but well-characterised entity predominantly involving the lower oesophagus. Co-morbidity-such as diabetes mellitus, hypertension, chronic liver or kidney or pulmonary disease-predisposes to this condition. On endoscopy, it appears as a diffuse, circumferential, black discolouration. Though poorly understood, tissue hypoperfusion appears central to its pathogenesis. Tackling the underlying predisposing co-morbidity and supportive management are the mainstay of therapy. Despite early diagnosis and prompt treatment, the outcome may be unfavourable and is related to the underlying aetiology. We report a case series of three patients of acute oesophageal necrosis who presented to us with symptoms of acute upper gastrointestinal bleeding and improved with conservative management.

[Endoscopic Diagnosis of Aortoesophageal Fistula Not Presenting Hematemesis].

Aortoesophageal fistula (AEF) is an extremely rare but lethal cause of massive gastrointestinal hemorrhage. Characteristic symptoms are mid-thoracic pain, sentinel minor hemorrhage, and massive hemorrhage after a symptom-free interval. Prompt diagnosis and immediate treatments are necessary to reduce mortality. However, AEF is difficult to diagnose because it is uncommon and often leads to death with massive bleeding before proper evaluation. We report a case of endoscopic diagnosis of AEF that did not present with hematemesis; it was treated with thoracic endovascular aortic repair (TEVAR) and surgery. A 71-year-old female presented to the emergency department with epigastric discomfort. Endoscopy demonstrated a submucosal tumor-like protrusion and pulsating mass with blood clots. Contrast-enhanced chest CT confirmed AEF due to descending thoracic aortic aneurysm. The patient immediately underwent TEVAR to prevent massive bleeding and subsequently underwent surgery. Endoscopists should consider AEF if they see a submucosal tumor-like mass with a central ulcerative lesion or a pulsating protrusion covered with blood clots in mid-esophagus during an endoscopy.

[Gastric schwannoma: rare differenzial diagnosis of acute upper gastrointestinal (GI) bleeding]. / Schwannom des Magens: seltene Differenzialdiagnose einer akuten oberen gastrointestinalen Blutung.

Schwannomas are benign tumors derived from Schwann cells and their typical site of origin is the subcutaneous tissue of the extremities. Gastrointestinal localization of Schwannomas is extremely rare and the stomach is the prevalent site. Gastric schwannomas primarily occur in the gastric submucosa and are usually asymptomatic.We present a rare case of a solitary gastric schwannoma in a 51-year old male, which initially manifested with hematemesis by acute upper gastrointestinal (GI) bleeding. The upper GI-Endoscopy revealed a gastric submucosal tumor, 7 cm in size, located in the proximal corpus and fundus. In the endoscopical Ultrasound (EUS-Examination), the lesion appeared to arise from the fourth proper muscle layer (Muscularis propria). The fourth layer origin and the isoechogenicity, as compared to the normal muscle layer, are endoscopic ultrasonographic characteristics of gastric schwannomas and help in distinguishing them from gastrointestinal tumors (GIST). Because of the unclear histological identity, the patient underwent a "rendezvous" endoscopic-laparoscopic surgical resection of the tumor in toto. The histomorphological features of the lesion and the strong expression of S100 in combination with absence of DOG1 expression indicated the diagnosis of gastric schwannoma. There was no evidence of malignancy. The postoperative course was uncomplicated.This is a very rare manifestation of gastric schwannoma, representing a rare differenzial diagnosis in a case of acute upper GI-Bleeding. Only 14 % of gastric schwanommas are presented with gastrointestinal bleeding, including mainly melena rather than hematemesis. This case is considered to be worthy of presentation owing to the rare and unusual cause of upper GI bleeding implied in it.

Comportamiento de la hemorragia digestiva alta en el quinquenio 2009 a 2013 / Behavior of the high digestive bleeding in the five-year period 2009-2013

Introducción: la hemorragia digestiva alta constituye un problema frecuente de salud en el mundo; así se comporta en Cuba, en la provincia Matanzas y en el hospital de estudio. Actualmente es considerada como causa mayor de morbimortalidad. Objetivo: determinar el comportamiento de la hemorragia digestiva alta en el Hospital Militar de Matanzas. Materiales y Métodos: se realizó una investigación descriptiva, en un periodo de cinco años que incluyó a todos los pacientes ingresados con ese diagnóstico, y los que durante su ingreso por otra causa presentaron episodios de hemorragia. El índice de Rockall permitió evaluar la necesidad de cirugía, recidiva y mortalidad. Resultados: la mayoría de los pacientes pertenecieron al grupo de riesgo intermedio. Los hombres fueron los más afectados, el grupo de tercera edad presentó mayor incidencia. La gastritis hemorrágica fue la primera causa de sangrado. La hipertensión arterial resultó ser el factor de riesgo relevante y el tabaquismo el hábito tóxico más frecuente. Conclusiones: como beneficio relevante se demostró la importancia de la endoscopia precoz para el diagnóstico de la causa, tratamiento y pronóstico de la hemorragia. Se observó una buena correlación entre el pronóstico del paciente al ingreso y su estado al final del tratamiento (AU).

Introduction: the high digestive hemorrhage is a frequent health problem in the world; it behaves the same in Cuba, in the province of Matanzas and in the hospital where the study was carried out. Currently it is considered a major cause of morbi-mortality. Objective: to determine the behavior of the high digestive bleeding in the Military Hospital of Matanzas. Materials and Methods: a descriptive research was carried out in a five-year period. It included all the patients admitted with that diagnosis and those who presented episodes of hemorrhage even if they were admitted by any other cause. The Rockall index allowed to assess the necessity of surgery, the recidivism and mortality. Results: most of the patients belonged to the intermediate risk group. Male patients were the most affected one; the group of elder people showed higher incidence. Hemorrhagic gastritis was the first cause of bleeding. Arterial hypertension was the relevant risk factor and smoking the most frequent toxic habit. Conclusions: as a relevant benefit it was showed the importance of precocious endoscopy for the diagnosis of the hemorrhage cause, treatment and prognosis. It was observed a good correlation between the patient´s prognosis at the admission and his status at the end of the treatment (AU).

Comportamiento de la hemorragia digestiva alta en el quinquenio 2009 a 2013 / Behavior of the high digestive bleeding in the five-year period 2009-2013

Introducción: la hemorragia digestiva alta constituye un problema frecuente de salud en el mundo; así se comporta en Cuba, en la provincia Matanzas y en el hospital de estudio. Actualmente es considerada como causa mayor de morbimortalidad. Objetivo: determinar el comportamiento de la hemorragia digestiva alta en el Hospital Militar de Matanzas. Materiales y Métodos: se realizó una investigación descriptiva, en un periodo de cinco años que incluyó a todos los pacientes ingresados con ese diagnóstico, y los que durante su ingreso por otra causa presentaron episodios de hemorragia. El índice de Rockall permitió evaluar la necesidad de cirugía, recidiva y mortalidad. Resultados: la mayoría de los pacientes pertenecieron al grupo de riesgo intermedio. Los hombres fueron los más afectados, el grupo de tercera edad presentó mayor incidencia. La gastritis hemorrágica fue la primera causa de sangrado. La hipertensión arterial resultó ser el factor de riesgo relevante y el tabaquismo el hábito tóxico más frecuente. Conclusiones: como beneficio relevante se demostró la importancia de la endoscopia precoz para el diagnóstico de la causa, tratamiento y pronóstico de la hemorragia. Se observó una buena correlación entre el pronóstico del paciente al ingreso y su estado al final del tratamiento (AU).

Introduction: the high digestive hemorrhage is a frequent health problem in the world; it behaves the same in Cuba, in the province of Matanzas and in the hospital where the study was carried out. Currently it is considered a major cause of morbi-mortality. Objective: to determine the behavior of the high digestive bleeding in the Military Hospital of Matanzas. Materials and Methods: a descriptive research was carried out in a five-year period. It included all the patients admitted with that diagnosis and those who presented episodes of hemorrhage even if they were admitted by any other cause. The Rockall index allowed to assess the necessity of surgery, the recidivism and mortality. Results: most of the patients belonged to the intermediate risk group. Male patients were the most affected one; the group of elder people showed higher incidence. Hemorrhagic gastritis was the first cause of bleeding. Arterial hypertension was the relevant risk factor and smoking the most frequent toxic habit. Conclusions: as a relevant benefit it was showed the importance of precocious endoscopy for the diagnosis of the hemorrhage cause, treatment and prognosis. It was observed a good correlation between the patient´s prognosis at the admission and his status at the end of the treatment (AU).

Gastric inflammatory fibroid polyp mimicking a gastrointestinal stromal tumor

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The "different face" of esophageal cancer: cutaneous manifestation of visceral malignancies.

Squamous cell carcinoma is the most common type of neoplasm of the esophagus with global incidence. Its early symptoms are often nonspecific as the disease could be detected only when metastases in various organs are already presented. Esophageal metastases present an extremely small part from all cutaneous metastases as the real incidence of cutaneous metastases due to cancer of the esophagus account for 0.5-9 % and only a small part of them are reported and rarely involve the facial region. Despite this, cutaneous metastases may be the first sign of malignancy of the esophagus, which immediately determined the worst prognosis and fatal outcome in these patients. Average survival prognosis at the time of diagnosis of esophageal carcinoma in stage IV is 4-6 months, while the survival-associated expectations in cases of associated skin lesions manifestation is 4 months. We present a rare case of esophagus carcinoma in advanced stage, presented with severe cutaneous metastasis in the face region, accompanied by heavy blood coughing and hematemesis, which led to fatal outcome in the reported patient. The incidence of cutaneous metastases due to this visceral malignancy is discussed, as we highlight the frequency of metastases as a first clinical sign in esophageal cancer. The mortality rate is high due to the advanced stage of progression of the disease or presented metastases spread at the time of diagnosis, while treatment-related mortality accounts 10.3 %.

Advances and pitfalls in the management of small bowel polyps in Peutz-Jeghers syndrome

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Brote epidémico de gastritis hemorrágica asociado a una infección aguda por enterovirus / Hemorrhagic gastritis outbreak associated to acute enterovirus infection

Pacientes y métodos: Seis niños de 4-8 años de edad, 4 varones, con hematemesis y/o melenas, fueron diagnosticados de gastritis hemorrágica aguda en un periodo de 6 semanas durante los meses de octubre y noviembre de 2007. Se realizaron las siguientes pruebas: hemograma, pruebas de coagulación, frotis faríngeo y rectal para virus, bacterias y hongos, serologías virales y serología y test de urea-C13 espirado para Helicobacter pylori. Resultados: Un niño presentaba un cuadro febril, 5 niños dolor abdominal, 6 hematemesis, 3 melenas y 3 heces negras. Ninguno de los niños sufría gastroenteritis aguda. Las pruebas de coagulación fueron normales en los 6 niños. Cuatro de los niños tenían un nivel de hemoglobina <8,5 g/dL. La endoscopia digestiva alta mostró signos de sangrado o de gastritis aguda en todos ellos. Se aisló el enterovirus Coxsackie A en los cultivos faríngeo y rectal del caso índice, y se detectó una serología de enterovirus IgM positiva en otros 3 casos. No se aisló ni identificó H. pylori u otros patógenos en ningún niño. Conclusiones: En 4 de los 6 niños con un brote epidémico de gastritis hemorrágica se pudo comprobar la asociación de infección aguda por enterovirus. La gastritis hemorrágica era una manifestación no descrita hasta ahora en las infecciones por enterovirus (AU)

Introduction: The acute hemorrhagic gastritis is a rare pathologyin pediatric age. There are no references in the medical literature of outbreaks of hemorrhagic gastritis. Patients and methods: Six children between 4 and 8 years of age, 4 males, with hematemesis and/or melenas were diagnosed with acute hemorrhagic gastritis in a period of 6 weeks during the months of October and November 2007. Different exams were carried out: full blood count, clotting tests, rectal and pharyngeal swabs for viruses, bacteria and fungi, viral serology’s and C-13 urea breath test for Helicobacter pylori. Results: One child had fever, 5 children abdominal pain, 6children hematemesis, 3 melenas and 3 black feces. None of the children had signs or symptoms of acute gastroenteritis. The coagulation test was normal in the children. Four of the children had hemoglobin below 8.5 g/dL. The upper digestive endoscopy (UDE) showed signals of bleeding or of acute gastritis in all of them. The enterovirus Coxsackie virus A was isolated in the pharynx and rectal culture of the first patient and in 3 other cases. IgM positive serology for enterovirus was found in one patient. Helicobacter pylori or other pathogens were not found in any child. Conclusions: In 4 of the 6 children an outbreak of hemorrhagic gastritis was verified with the relationship to the acute infection by enterovirus. The hemorrhagic gastritis was a manifestation, which had not been described until now in enterovirus infections (AU)

[A rare cause of haematemesis with fatal gastrointestinal bleeding]. / Seltene Ursache einer Hämatemesis mit letalem Ausgang.

A 73-year-old man was admitted to the hospital due to severe hematemesis and collapse, severe anemia and inflammation. Two months ago, the patient had been treated with antibiotics due to septicemia with staphylococcus aureus. At that time CT scan had shown only thoracic arteriosclerosis. The subsequent high urgency upper endoscopy identified a circular mucosal defect in distal esophagus as bleeding origin. The patient died 10 hours after admission. Performing autopsy, a fistula between the thoracic aortic aneurysm and the distal esophagus was found in the background of severe arteriosclerosis. The rapid onset of an aneurysm with rupture after a bacterial infection is typical for a mycotic aneurysm.

An aortoesophageal fistula in patient with lung cancer after chemo-irradiation and subsequent esophageal stent implantation.

An aortoesophageal fistula (AEF) is uncommon but is frequently fatal. Most cases are attributable to a thoracic aortic aneurysm. Other common causes include malignant intrathoracic neoplasm, foreign body ingestion, endovascular stent graft repair for thoracic aortic disease, and esophageal surgery. We report a case of an AEF that developed after chemo-irradiation and subsequent esophageal stent implantation in patient with non-small cell lung cancer. The patient underwent self expanding metallic esophageal stent implantation for an esophageal stricture after chemotherapy and radiotherapy. However, 1 month later, he presented with hematemesis. Chest computed tomography and aortography revealed a fistula from the descending thoracic aorta to the stented esophagus. The patient expired 36 hours after initial hematemesis. To our knowledge, this is the first confirmed report of an AEF in patient with a nonesophageal malignancy that had undergone chemo-irradiation and subsequent esophageal stent implantation. We recommend that special caution be exercised when performing esophageal stent implantation in patients who have received prior radiotherapy to the thorax including the esophagus.

Aortoesophageal fistula due to caustic ingestion.

PURPOSE: Caustic agent ingestion may produce corrosive lesions that can extend beyond adjacent organs. We report three cases of aortoesophageal fistulas (AEF) after caustic ingestion that were diagnosed by autopsy. RESULTS: AEF is a fatal complication that should be suspected in any patient with caustic ingestion who presents with gastrointestinal bleeding. A high index of suspicion, early recognition by gastrointestinal endoscopy, computed tomography scan, and aortography are important to improve the outcome.