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Abstract

Introduction: Acute esophageal necrosis (AEN), commonly referred to as "black esophagus", is a rare disease. Its endoscopic finding shows diffuse circumferential black mucosal discoloration in the distal esophagus. The etiology of AEN is multifactorial; a combination of an ischemic insult to the esophagus, impaired mucosal barrier systems, and a chemical injury from backflow of gastric secretions. We present a case of AEN, whose etiology is thought to be an ischemia due to alcoholic ketoacidosis (AKA). Case Description: A 48-year-old male, with a history of alcohol abuse, presented to the ED complaining of coffee ground emesis. He was in shock state on admission (BP 88/62 mmHg, HR 127 beats/min) with a score of 13 on the Glasgow coma scale. Arterial blood gas showed raised anion gap metabolic acidosis with elevated ketone bodies including beta-hydroxybutyrate. From these findings, we diagnosed as a case of AKA associated with dehydration. Initial endoscopic evaluation on admission revealed a black esophagus in the distal one-third, with clear-cut margin at the gastroesophageal junction. Hemodynamic state was recovered by aggressive fluid resuscitation, and severe metabolic acidemia was also improved by continuous renal replacement therapy. Lansoprazole had also been started on admission. Secondary endoscopic examination on day 10 showed a mixture of residual black areas and ulcer formation covered with thick white exudates. Third endoscopic examination on day 25 showed the regeneration of the esophagus mucosa. The patient was discharged without any complications on day 49. Discussion: AEN is a very rare condition and its estimated prevalence is 0.01%-0.28%. The mortality of AEN is reported to be up to 30%, depending on the underlying medical condition. In this case, dehydration and AKA associated with malnutrition were the main causes of the hemodynamic instability, which led the ischemia of distal esophagus. Conclusion: AEN is potentially fatal disease despite of its low prevalence. It should be considered as the differential diagnosis of upper GI bleeding.