S4257 Beyond the Usual Suspects: Acute Esophageal Necrosis in a 48-Year-Old With Alcohol Use Disorder

Introduction: Acute esophageal necrosis (AEN), also known as “black esophagus,” is a rare condition with an endoscopic prevalence of 0.01–0.28%. It is characterized by circumferential black discoloration of the esophageal mucosa. AEN predominantly affects older men (mean age 68) and is associated with poor nutritional status, alcohol use, and multiple comorbidities. Hematemesis and melena are the most common presenting symptoms, though diagnosis is often incidental during esophagogastroduodenoscopy. Although typically self-limited with supportive care, AEN carries a high mortality rate (13%–35%), often related to underlying disease, with direct complications, including perforation, stricture, and severe hemorrhage, accounting for a smaller subset. Case Description/Methods: A 48-year-old man with a history of alcohol use disorder presented after a witnessed seizure. He reported daily alcohol consumption and poor nutrition. Vitals revealed tachycardia, and labs showed severe hyponatremia and elevated lactate. Ethanol level was undetectable. Hypertonic saline was administered with a central line. Subsequently, he developed new-onset atrial fibrillation with rapid ventricular response and hypotension, treated with digoxin and enoxaparin. The patient then had hematemesis, which he later disclosed had occurred intermittently for one week. His hemoglobin dropped from 14.0 g/dL to 10.2 g/dL within eight hours, and he developed melena. Management included pantoprazole, octreotide, and a massive transfusion protocol. Esophagogastroduodenoscopy revealed diffuse circumferential black discoloration and ulceration throughout the esophagus, consistent with AEN. Gastric and duodenal mucosa appeared normal. The patient was managed with nil per os status and intravenous proton pump inhibitor therapy, before gradually resuming oral intake. He was discharged in stable condition to a substance use rehabilitation facility after 9 days. Discussion: Acute esophageal necrosis is a rare condition that typically affects older male patients with multiple medical comorbidities, making this an atypical presentation in a young adult whose medical history is significant only for alcohol use disorder. Furthermore, while acute esophageal necrosis often presents with upper gastrointestinal bleeding, severe bleeding complications—such as those exhibited by this patient requiring massive transfusion—are rare. Early recognition and aggressive supportive care are essential for favorable outcomes.