{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,21]],"date-time":"2026-05-21T10:11:19Z","timestamp":1779358279611,"version":"3.51.4"},"reference-count":10,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2026,5,21]],"date-time":"2026-05-21T00:00:00Z","timestamp":1779321600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>A 65-year-old man with type 2 diabetes presented with abdominal pain. Although he had no typical reflux symptoms such as heartburn or acid regurgitation, esophagogastroduodenoscopy (EGD) showed findings suggestive of reflux esophagitis, and proton pump inhibitor therapy was initiated. Two months later, he was admitted with intractable vomiting. EGD demonstrated diffuse circumferential mucosal injury without black discoloration, predominantly in the distal esophagus. These findings were interpreted as severe reflux esophagitis (Los Angeles grade D; RE-D). Symptoms improved with supportive care, glycemic control, and continued PPI therapy; follow-up EGD showed marked improvement. Six months later, he re-presented with identical symptoms and endoscopic findings. Laboratory testing confirmed diabetic ketoacidosis (DKA), with ketonuria, elevated total ketone bodies (2469 \u00b5mol\/L), and high-anion gap metabolic acidosis (anion gap 17.2 mEq\/L). The diagnosis was revised to DKA-associated acute esophageal mucosal lesion (AEML). He improved with fluid resuscitation and insulin therapy, and medication adherence was reinforced. Follow-up EGD showed complete healing without recurrence. AEML has been proposed as a spectrum that includes acute esophageal necrosis (AEN; \u201cblack esophagus\u201d) and esophagitis without black-appearing mucosa. This case highlights a diagnostic pitfall in which DKA-associated AEML without black discoloration may be misattributed to severe reflux esophagitis. When the clinical presentation or endoscopic appearance is severe or atypical, clinicians should consider AEML and evaluate for underlying systemic precipitants.<\/jats:p>","DOI":"10.3390\/diagnostics16101566","type":"journal-article","created":{"date-parts":[[2026,5,21]],"date-time":"2026-05-21T09:29:58Z","timestamp":1779355798000},"page":"1566","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Acute Esophageal Mucosal Lesion Mimicking Severe Reflux Esophagitis in Diabetic Ketoacidosis: A Diagnostic Pitfall"],"prefix":"10.3390","volume":"16","author":[{"given":"Yohei","family":"Midori","sequence":"first","affiliation":[{"name":"Department of Gastroenterology, Fukui General Hospital, 28-16-1, Egami-Cho, Fukui 910-8561, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Koji","family":"Hayashi","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, Fukui General Hospital, 28-16-1, Egami-Cho, Fukui 910-8561, Japan"},{"name":"Department of Neurology, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji-Cho, Yoshida-Gun, Fukui 910-1193, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maho","family":"Hayashi","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Fukui General Hospital, 28-16-1, Egami-Cho, Fukui 910-8561, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hidetaka","family":"Matsuda","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Fukui General Hospital, 28-16-1, Egami-Cho, Fukui 910-8561, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,21]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1136\/gut.45.2.172","article-title":"Endoscopic assessment of oesophagitis: Clinical and functional correlates and further validation of the Los Angeles classification","volume":"45","author":"Lundell","year":"1999","journal-title":"Gut"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1111\/j.0915-5635.2006.00608.x","article-title":"Twelve cases of acute esophageal mucosal lesion","volume":"18","author":"Tsumura","year":"2006","journal-title":"Dig. Endosc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1159\/000492492","article-title":"A comparison of clinical characteristics of patients with acute esophageal mucosal lesion and those with severe reflux esophagitis","volume":"99","author":"Sakata","year":"2019","journal-title":"Digestion"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"3219","DOI":"10.3748\/wjg.v16.i26.3219","article-title":"Black esophagus: Acute esophageal necrosis syndrome","volume":"16","author":"Gurvits","year":"2010","journal-title":"World J. Gastroenterol."},{"key":"ref_5","first-page":"3775","article-title":"Examination of the severity of subtypes of acute esophageal mucosal lesion","volume":"56","author":"Tatsumi","year":"2014","journal-title":"Gastroenterol. Endosc."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"408","DOI":"10.4240\/wjgs.v15.i3.408","article-title":"Clinical features of acute esophageal mucosal lesions and reflux esophagitis Los Angeles classification grade D: A retrospective study","volume":"15","author":"Ichita","year":"2023","journal-title":"World J. Gastrointest. Surg."},{"key":"ref_7","first-page":"642","article-title":"Clinical features and pathophysiology of acute esophageal mucosal lesion","volume":"113","author":"Ihara","year":"2016","journal-title":"Nihon Shokakibyo Gakkai Zasshi"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Kitawaki, D., Nishida, A., Sakai, K., Owaki, Y., Nishino, K., Noda, Y., and Imaeda, H. (2022). Gurvits syndrome: A case of acute esophageal necrosis associated with diabetic ketoacidosis. BMC Gastroenterol., 22.","DOI":"10.1186\/s12876-022-02349-z"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1159\/000504434","article-title":"Black esophagus in the setting of diabetic ketoacidosis: A rare finding from our institution","volume":"13","author":"Ghoneim","year":"2019","journal-title":"Case Rep. Gastroenterol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.2337\/dci24-0032","article-title":"Hyperglycemic crises in adults with diabetes: A consensus report","volume":"47","author":"Umpierrez","year":"2024","journal-title":"Diabetes Care"}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/10\/1566\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,21]],"date-time":"2026-05-21T09:53:00Z","timestamp":1779357180000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/10\/1566"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,21]]},"references-count":10,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["diagnostics16101566"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics16101566","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,21]]}}}