Necrotizing Oesophagitis Associated with Ketoacidosis: A Case Series Exploring the Diagnostic Dilemma of Metabolic...

Necrotizing esophagitis, or acute esophageal necrosis (AEN), is a rare but serious cause of upper gastrointestinal bleeding, typically associated with critical illness. While traditionally linked to hypoperfusion states, its occurrence in metabolic emergencies-particularly where diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA), and starvation ketosis overlap-remains underrecognized.

We present a case series of four patients admitted to a rural Indian hospital with upper gastrointestinal bleeding in the setting of severe metabolic derangement, all diagnosed with AEN on upper gastrointestinal endoscopy.

Case 1 involved a patient with type 2 diabetes and chronic alcohol use presenting an "overlap syndrome" with extreme lactate elevation (11.6 mmol/L), biochemical pancreatitis (lipase 534 IU/L), and normal ultrasound. Case 2 demonstrated "pseudo-DKA" with normal glycated hemoglobin (HbA1c) (5.9%) and acute pancreatitis [lipase 1,946 IU/L, computed tomography (CT)-confirmed]. Case 3 represented a "cytokine tsunami" with thyroid storm, DKA, and multi-drug resistant (MDR) sepsis culminating in grade D necrotizing esophagitis. Case 4 illustrated "two hits from the same bottle"-AKA with portal hypertensive gastropathy (PHG). All patients improved with conservative management. No deaths occurred.

Acute esophageal necrosis should be considered when upper GI bleeding complicates ketoacidosis. The underlying etiology is often multifactorial, requiring clinicians to look beyond simple diagnostic labels. Recognizing distinct clinical patterns-overlap syndromes, pseudo-DKA, cytokine storms, and dual alcohol-related pathologies-may aid in early diagnosis and severity assessment in resource-limited settings.