Black Esophagus: A Life-Threatening Consequence of Hypoperfusion

Acute esophageal necrosis (AEN) is an uncommon endoscopic finding characterized by a patchy or diffuse circumferential black pigmentation of the esophageal mucosa, corresponding to ischemic necrosis. It usually presents with upper gastrointestinal bleeding and is thought to be caused by a systemic low blood flow in patients with predisposing risk factors, like advanced age and cardiovascular comorbidities. After initial hemodynamic stabilization, diagnosis is established by esophagogastroduodenoscopy (EGD) with careful biopsies and histological evaluation. Delayed diagnosis is thought to be the main cause of panesophageal necrosis, perforation, mediastinitis and septic shock. We present a case of AEN triggered by hypoperfusion due to severe perioperative blood loss in a 72-year-old woman with a history of cardiovascular disease. Even though she was stabilized during surgery, she still presented with melena 24 hours after, and endoscopic examination showed ischemic patches consistent with AEN. After administering intravenous fluids, proton pump inhibitors (PPI) and parenteral nutrition, a repeat EGD after 72 hours showed a neat improvement with erosive and ulcerative lesions replacing the black patches and a complete healing after eight weeks of oral PPI therapy. AEN is a rare but highly deadly entity that endoscopists must be aware of, especially in patients with multiple comorbidities and presenting with gastrointestinal bleeding after an episode of hemodynamic instability. Quick management can significantly improve survival.