Acute Esophageal Necrosis (AEN) or, Black esophagus is a rare clinical pathology characterized as diffuse, circumferential, necrosis of esophageal mucosa mainly in the distal part of esophagus detected with esophagogastroduodenoscopy (EGD). It's usually associated with multiorgan dysfunction with high mortality rate of 30%. A 61 years-old Male with the history of DM-II, Hypothyroidism, and Duodenal perforation transported from the nursing home with accidental extrication of PEG. Six months prior to admission, patient had history of duodenal ulcer, complicated with Sepsis transpiring to undergo tracheostomy and PEG placement. Vital signs were within normal limits. On examination, abdomen was non-distended with no stigmata of secretions or blood from patent PEG tube-insertion site. Initial investigations showed BUN 54 mg/dl with creatinine 0.9 mg/dl, hemoglobin 10.9 g/dl, leukocytosis (29.4 K/mm3) with bandemia (11% of WBC count), and INR 1.1, Hypoalbuminemia (2.4 g/dl) was noted along with elevated alkaline phosphatase (84 IU/L) and Alanine Aspartate (61 U/L). Patient was started on crystalloid fluids, broad-spectrum antibiotics for presumptive diagnosis of aspiration pneumonia as the chest X-ray showed infiltrate, and intravenous pantoprazole drip. Patient's vital signs remained stable along with hemoglobin ranging above 9 g/dl, was scheduled for Esophagogastroduodenoscopy (EGD). EGD showed severe esophagitis with diffuse dark mucosal discoloration, erosion and profound ulceration in entire esophagus suggestive of ischemic necrosis, this rare condition is known as Black Esophagus (Acute Esophageal Necrosis), next day patient developed severe hemoptysis leading to cardiac arrest, unfortunately patient didn't survive. This case illustrates patients with average age of 65 years old with multiple co-morbidities, such as diabetes or respiratory failure presenting with hematemesis, AEN should be part of differential diagnosis until endoscopic evaluation completes. Treatment consists of supportive therapy with initial management consists of intravenous hydration, correcting anemia with packed red blood cell transfusion, nil-per-os, and proton-pump inhibitor.1819_A Figure 1. Endoscopic view showing middle third of esophagus with severe mucosal changes with erosion and beginning of ischemic changes1819_B Figure 2. Lower third of the esophagus with diffuse circumferential black necrotic mucosa