Acute Esophageal Necrosis Secondary to Gastric Volvulus Presenting With Massive Aspiration of Upper Gastrointestinal Contents: A Case Report

Acute esophageal necrosis (AEN), or <i>black esophagus</i>, is a rare endoscopic syndrome typically encountered in critically ill patients. AEN associated with gastric volvulus is particularly uncommon and may be underrecognized when volvulus appears clinically asymptomatic. An 87-year-old woman admitted for pelvic fractures was incidentally found on CT to have a large paraesophageal hernia with organoaxial gastric volvulus and suspected gastric outlet obstruction, without gastrointestinal symptoms. She developed acute hypoxemic respiratory failure; during emergent intubation, a large volume of upper gastrointestinal contents (coffee-ground material) refluxed into the airway, consistent with massive aspiration. Bedside esophagogastroduodenoscopy relieved a functional obstruction in the upper third of the esophagus consistent with volvulus reduction and revealed extensive circumferential AEN with proximal extension. Despite supportive management, she progressed to septic shock with multiorgan failure and died after transition to comfort-focused care. This case highlights that paraesophageal hernia-associated organoaxial gastric volvulus can deteriorate abruptly with life-threatening aspiration despite an initially absent gastrointestinal symptom burden, underscoring the need for early recognition and close monitoring.