S4186 Acute Esophageal Necrosis in Critical Illness: A Case Series on Pathophysiology, Endoscopic Findings, and Outcomes

Introduction: Acute esophageal necrosis (AEN), commonly termed “black esophagus,” is a rare but severe gastrointestinal condition characterized by diffuse esophageal mucosal ischemia, often precipitated by shock states, metabolic disorders, and systemic infections. The pathophysiology involves hypoperfusion, mucosal barrier dysfunction, and oxidative stress, leading to necrosis and ulceration. Gastrointestinal bleeding is a frequent complication. This case series highlights patients presenting with AEN in distinct clinical settings. Case Description/Methods: Case 1: A 70-year-old man with heart failure, pneumonia, and acute-on-chronic kidney disease developed staphylococcus aureus catheter-associated bacteremia, resulting in septic shock. During hospitalization, he presented with coffee-ground emesis and melena. EGD revealed blackish mucosa extending from 22 cm to 36 cm from the dental arch, with grayish and erythematous regions, suggestive of ischemic necrosis. Treatment with proton pump inhibitor infusion, vasopressors, and antibiotics led to clinical improvement. The patient recovered and was discharged. Case 2: A 67-year-old woman with type 2 diabetes mellitus, acute myocardial infarction, and cardiogenic shock was admitted with dyspnea, chest pain, and fluid overload. During hospitalization, she developed melena and acute anemia, prompting EGD, which revealed necrosis, fibrosis, erosions, and mucosal bleeding from the middle to distal esophageal third, consistent with AEN. Conservative management was pursued. Case 3: A 62-year-old woman in intensive care with septic shock secondary to hospital-acquired pneumonia and moderate acute respiratory distress syndrome was mechanically ventilated and remained refractory to vasoactive amines. During hospitalization, she developed hematemesis, prompting EGD, which revealed ulcerations covered in fibrin, extensive mucosal discoloration affecting 75% of the esophageal circumference. These findings confirmed AEN. Discussion: AEN is an underrecognized clinical entity with high morbidity, often linked to circulatory shock and metabolic derangements. Early endoscopic assessment plays a critical role in diagnosis, guiding therapeutic decisions and prognosis. While proton pump inhibitors and supportive care remain the mainstay of treatment, follow-up endoscopy may be warranted in severe cases to monitor resolution. This case series highlights the importance of recognizing AEN in critically ill patients, emphasizing its multifactorial nature and the role of timely intervention.