Black Esophagus: A Rare Case of Acute Esophageal Necrosis Induced by Diabetic Ketoacidosis in a Young Adult Female

Abstract

Background Acute esophageal necrosis is an uncommon clinical disorder diagnosed on endoscopy as a black esophagus. It has a multifactorial etiology that probably represents a combination of poor nutritional status, gastric outlet obstruction, and ischemia secondary to hypoperfusion of the distal esophagus. It typically occurs in older males with comorbidities. Case A 37-year-old woman presented with diabetic ketoacidosis and hematemesis. At esophagogastroduodenoscopy acute esophageal necrosis was diagnosed. The treatment included fluid and electrolyte management, insulin, and a proton pump inhibitor. She improved and left the hospital on day 3. Conclusion Diabetic ketoacidosis can result in a profound osmotic diuresis, fluid loss, and hypoperfusion of the distal esophagus. This condition can then lead to ischemic injury and acute esophageal necrosis. Awareness of the possibility of its presence in young women with hematemesis and poorly controlled diabetes is important since early identification with esophagogastroduodenoscopy is necessary to prevent serious postnecrotic complications.

Black Esophagus in the Setting of Diabetic Ketoacidosis: A Rare Finding from Our Institution

“…All of our patients had underlying comorbidities that predisposed them to low perfusion states, and/or microvascular vasculopathies. Further, all of them presented with diabetic ketoacidosis with subsequent endoscopic findings of AEN [12][13][14][15]. Interestingly, one of our female patients presented with diabetic ketoacidosis and necrotizing esophagitis without a prior diagnosis of diabetes mellitus.…”

“…AEN is a rare cause of severe injury to the esophagus [7][8][9][10][11][12][13]. It has an endoscopic appearance characterized by diffuse, circumferential black discoloration of the mucosa that affects the distal esophagus and stops abruptly at the gastroesophageal junction [1][2][3][4][5][6][7].…”

“…It is hypothesized that due to the smaller caliber of lower segment feeding vessels, corresponding areas of the distal esophagus are predisposed to more ischemic insults and necrosis during hypoperfusion states. A "two-hit" model has been proposed and identifies ischemia as the key player in the manifestations of the disease, with some form of gastric outlet obstruction perpetuating the causative insult of reflex acid and contributing to the breakdown of mucosa [6][7][8][9][10][11][12][13]. A neutrophilic response then ensues as a result of epithelial damage or secondary to infection.…”

“…Poor nutritional status and general deconditioning may also contribute to reduced mucosal buffering and may potentiate the mechanisms by which esophageal necrosis is accelerated [5,[11][12][13]. The diagnosis is achieved by visualizing the blackened segment of the esophagus with biopsies obtained to exclude other etiologies [1][2][3][4][5][6][7][8][9][10][11][12][13][14]. Black esophagus affects men more so than women with a peak incidence in the sixth decade of life [2,14].…”

“…Multiple comorbidities increase the likelihood of AEN. Specifically, hyperglycemia is seen in almost 90% of patients with this condition [12][13][14][15]. All of our patients had underlying comorbidities that predisposed them to low perfusion states, and/or microvascular vasculopathies.…”