S4248 Black Esophagus in Pancreatic Cancer-Associated Necrotizing Pancreatitis: A Case Report and Review of the Literature

Introduction: Acute esophageal necrosis (AEN) is a rare condition marked by circumferential black discoloration of the esophageal mucosa, typically seen in shock or critical illness. While pancreatitis and malignancy have been separately linked to AEN, their co-occurrence has not been previously reported. We present a fatal case of AEN associated with necrotizing pancreatitis and newly diagnosed metastatic pancreatic adenocarcinoma. Case Description/Methods: A 75-year-old man with recurrent idiopathic acute pancreatitis presented with abdominal pain, ascites, and diffuse lymphadenopathy. Lipase was elevated at 259 U/L (ref. 9-63 U/L). Computed tomography showed a lobulated, hypodense pancreatic mass with fat stranding, concerning for necrotizing pancreatitis. Magnetic resonance cholangiopancreatography showed pancreatic ductal dilation without gallstones. Cytology from ascitic fluid and lymph node biopsy confirmed metastatic adenocarcinoma. On hospital day 4, the patient developed coffee-ground emesis. Upper endoscopy revealed diffuse black discoloration and ischemic changes throughout the esophagus consistent with AEN. Conservative management included intravenous pantoprazole (8 mg/h), fluid resuscitation, and avoidance of nasogastric tubes and NSAIDs. He developed sepsis with multiorgan failure within 24 hours and died. No autopsy was performed. Discussion: AEN is rare, seen in 0.01-0.28% of upper endoscopies with a 30-day mortality rate of 20-30%, and is thought to result from severe ischemic or chemical injury. While most cases are associated with hypovolemia or gastric outlet obstruction, malignancy and pancreatitis are less common. Malignancy is present in 10%–29% of AEN cases; however, pancreatic cancer is rare, with only 3 published cases. One review reported pancreatitis in 4.5% of AEN cases. A separate review of 319 patients with AEN found benign pancreatic disease in 6.9%, with 4 necrotizing pancreatitis cases—3 alcohol-related, 1 gallstone-related. Our case uniquely describes AEN secondary to pancreatic cancer-associated necrotizing pancreatitis. Although our patient had a Ranson score of 4, typically associated with 15% mortality, his rapid decline after AEN onset suggests it may signal irreversible decompensation not captured by initial severity indices. This case underscores the importance of early endoscopy for GI bleeding in critically ill patients and suggests AEN may serve as a prognostic marker with implications for management and goals-of-care discussions.