S4200 Black Esophagus in a Nonagenarian With Hematemesis: A Case of Acute Esophageal Necrosis With Mucosal Recovery

Introduction: Acute esophageal necrosis (AEN), also known as “black esophagus,” is a rare but serious manifestation of ischemic injury to the esophagus. It is characterized by diffuse circumferential black discoloration of the esophageal mucosa, most commonly affecting the distal esophagus with varying degrees of proximal extension. AEN is often multifactorial in origin, resulting from systemic hypoperfusion and critical illness that compromise mucosal integrity. Early recognition and timely supportive management are essential, particularly in patients with complex comorbidities that impair tissue perfusion. Case Description/Methods: A 93-year-old man with multiple co-morbid conditions of atrial fibrillation on anticoagulation, congestive heart failure, pulmonary hypertension, diabetes mellitus, and severe aortic stenosis presented with coffee-ground emesis and melena. Emergent esophagogastroduodenoscopy revealed a confluence of necrotic-appearing mucosa in the mid-to-distal esophagus suggestive of AEN. Biopsies were obtained, which confirmed severe acute inflammation with prominent brown-black pigment deposition, consistent with necrotic tissue. The patient was managed conservatively with intravenous pantoprazole, total parenteral nutrition, hydration, and optimization of his underlying comorbidities. Given his advanced age and medical complexity, surgical intervention was deferred. Close hemodynamic monitoring and supportive management resulted in clinical stabilization and gradual recovery. A repeat esophagogastroduodenoscopy on day 7 demonstrated substantial mucosal healing. The patient was discharged on oral proton pump inhibitor therapy and has remained clinically stable without readmission. Discussion: This case highlights the importance of recognizing AEN in the appropriate clinical context and compatible endoscopic findings. Co-morbid conditions such as heart failure, aortic stenosis, and atrial fibrillation can compromise esophageal perfusion and impair mucosal defenses, increasing susceptibility to ischemic injury. Management of AEN involves not only measures to hasten mucosal healing, but also optimization of systemic perfusion and underlying medical conditions. Our patient’s successful recovery without surgical intervention illustrates the value of prompt recognition, diligent supportive care, and multidisciplinary in achieving favorable outcomes.