Fatal black esophagus and duodenum

Black esophagus (BE) is a rare finding characterized by a black appearance on the distal esophageal mucosa. In the forensic field, BE is often reported in cases of diabetic ketoacidosis and hypothermia. Coexistence of acute duodenitis (black duodenum) has also been reported. Serious complications, such as esophageal perforation and hemorrhagic shock from bleeding from the esophageal mucosa, can be life-threatening. We report a forensic autopsy case of a relatively young man who died of BE and black duodenum with no underlying conditions such as diabetes or alcohol/drug abuse. The patient was a 44-year-old man with a history of depression. He was found dead at home two days after visiting the doctor with vomiting and stomach pain. Internal inspection revealed stomach content of 1500 mL of black hematinized fluid. Black discoloration of the distal part of the esophageal and black discoloration on the duodenal mucosa, and pallor of the internal organs were observed. Blood acetone was 16 µg/mL and hemoglobin A1c was 5.6%. No alcohol was detected in the cardiac blood. The cause of death was considered to be exsanguination from the BE and black duodenum. Because the patient had presented with vomiting two days prior to death, the cause of the BE was considered to be esophageal mucosal injury due to vomiting or ischemic insult to the esophagus from dehydration. Although a large proportion of the causes of death in BE cases are associated with underlying medical conditions, forensic pathologists should keep in mind that BE itself could be life-threatening.