Black Esophagus: Rare and Deadly

Acute esophageal necrosis (AEN), also known as ‘black esophagus’ or ‘necrotizing esophagitis’, is a lifethreatening condition which causes diffuse circumferential black appearance of the distal esophagus. This condition is often seen in the critically ill and may be attributed to a vascular watershed area in the distal esophagus. The incidence of AEN varies in endoscopic series from 0.01 to 0.28%, thus signifying a very rare condition. A 73-year-old male with a past medical history of Stage IIIC rectal adenocarcinoma status post low anterior resection and diverting ileostomy presented with intractable nausea, vomiting and malaise. On admission, vitals showed blood pressure of 160/110 and heart rate of 110. Physical examination revealed epigastric abdominal tenderness with no peritoneal signs. Given mild leukocytosis of 11,000 and positive urinalysis patient was started on empiric antibiotics for presumed urinary tract infection. During the hospital course, patient developed acute change in mental status with 1300 milliliters of melenic ostomy output. Repeat vitals showed persistent hypertension and tachycardia with bloodwork showing hemoglobin drop of 2 grams from 14g to 12g with concomitant elevation of BUN to 100. Patient was started on intravenous protonix drip and taken for emergent upper endoscopy which showed diffuse severe mucosal changes characterized by circumferential mucosal necrosis in the entire esophagus extending from 15 cm from the incisors to the gastro-esophageal junction. Exam also revealed gastric erosions and multiple duodenal ulcers. Given the esophageal findings, patient was referred to cardiothoracic surgery for evaluation. Initial plan was to pursue an emergent esophagectomy however patient's family requested hospice care given the overall poor prognosis. Acute esophageal necrosis is associated with several comorbidities including multiorgan dysfunction, persistent hypoperfusion to internal organs, severe vasculopathies, sepsis, gastric volvulus, alcohol abuse or neoplastic diseases. The most frequent clinical presentation is melena, hematemesis, chest pain or dysphagia. Treatment is mainly supportive to maximize organ perfusion, optimize acid suppression and treat any underlying sepsis. Early surgical intervention may be required in cases of perforation, abscess or extent of injury. Clinicians should be aware of AEN in order to appropriately diagnose and manage the disease entity.1838 Figure 1. Diffuse severe mucosal changes seen in the lower third of the esophagus on EGD