The Dark side of the Esophagus: A Case report of Acute Esophageal Necrosis

Acute Esophageal necrosis (AEN) is a rare clinical entity, with fewer than 150 reported cases in literature and endoscopic prevalence ranging from 0.01 to 0.28%. First described by Goldenberg and later characterized by Gurvits in 2007, this condition predominantly affects the distal esophagus due to its relatively poor blood supply, resulting in its characteristic black appearance. AEN typically occurs in male patients with predisposing risk factors such as chronic liver disease, chronic kidney disease, alcoholism, malnutrition and cardiovascular comorbidities. It is also associated with sepsis and carries a high mortality rate. Upper gastrointestinal endoscopy remains the gold standard. Given the rarity of AEN, the standardized management guidelines are not well defined and the primary therapeutic focus remains on optimizing medical condition.
We present the case of an 81-year old female who presented with septic shock, profound hypoglycemia with hypothermia and workup revealed Acute Esophageal Necrosis. The development of AEN in our patient was multifactorial, with esophageal ischemia secondary to septic shock induced hypotension playing a key role. The condition may have been exacerbated by reduced cardiac output and vasoconstriction of splanchnic blood vessels secondary to hypothermia. Furthermore, gastric reflux likely contributed to additional mucosal injury. The patient was managed successfully with conservative yet aggressive approach with inotropic support, antibiotics and total parenteral nutrition.
We conclude that AEN should be considered in any patient with predisposing risk factors, particularly in presence of critical illness. This case highlights the urgent need for development of standardized guidelines to ensure timely diagnosis and optimal management for this rare but serious condition.