S4203 Acute Esophageal Necrosis in the Elderly: The Dark Consequence of Hypoperfusion

Introduction: Acute esophageal necrosis (AEN) or black “esophagus” is a rare and serious condition with circumferential black discoloration of the distal esophagus mucosa with sharp demarcation at the gastroesophageal junction. Its pathogenesis is multifactorial, involving systemic hypoperfusion, impaired mucosal defenses, and gastric reflux. Other factors include microbial colonization (e.g., nasogastric tube, sepsis) and ischemia-reperfusion injury. AEN commonly occurs in critically ill patients, especially in shock, malnutrition, sepsis, or comorbidities like diabetes, hypertension, and chronic kidney disease. Prevalence ranges from 0.1%-0.28% of endoscopies, highlighting its rarity despite severity. Mortality is 30%-35%, mainly due to underlying illness. Case Description/Methods: An 85-year-old woman with type 2 diabetes, hypertension, hypothyroidism, anemia, and multiple pressure ulcers admitted due to infected sacral ulcer. On hospital day 3, the patient developed hematemesis followed by melena over the next 3 days. Appeared pale and chronically ill, with abdominal tenderness, dry oral mucosa, a nasogastric tube. She was kept nothing per mouth, nasogastric tube removed, and high-dose proton pump inhibitors started. Esophagogastroduodenoscopy was placed once stable. During this time, she had persistent hypotension (SBP 72-102 mmHg, DBP as low as 48 mmHg), and hemoglobin drop from 9.7 to 71. G/dL over 4 days. On hospital day 7, esophagogastroduodenoscopy showed black mucosal discoloration of the mid to distal esophagus with clear transition at gastroesophageal junction, classic for AEN. The stomach was unremarkable, but 2 large duodenal ulcers with hematin deposits were noted. No biopsies were taken. The patient received conservative treatment, including IV fluids, blood transfusions, IV proton pump inhibitors, antibiotics and bowel rest. Despite management, her condition worsened and she died from progressive hemodynamic instability and multiorgan failure. Discussion: AEN is a rare but severe disorder with distinctive endoscopic findings. In this case multiple risk factors like advanced age, diabetes, malnutrition, and hypotension, likely caused esophageal ischemia. Duodenal ulcers may have worsened bleeding and perfusion. While biopsy may aid with diagnosis, it is unnecessary when clinical and endoscopic findings are classic. Management is supportive, but prognosis depends on underlying illness. This case highlights the importance of early recognition and vigilance in high-risk patients with upper gastrointestinal bleeding.