When a Fall Turns Black: Acute Esophageal Necrosis in a Frail Elderly Patient: A Rare Case Report

Abstract

Background: Acute esophageal necrosis (AEN), or black esophagus, is a rare and severe condition characterized by circumferential black discoloration and necrosis of the esophageal mucosa on endoscopy. It typically affects older patients with multiple comorbidities and is associated with upper gastrointestinal bleeding, high morbidity, and significant mortality. Herein, we report a unique case of AEN of an 87-year-old woman with a complex medical history who developed the condition in the context of acute physical trauma, physiological stress, hemodynamic instability, and pre-existing esophageal disease. This case highlights the multifactorial etiology of AEN and the challenges associated with managing such conditions in a frail elderly patient with multiple comorbidities.

The Case: An 87-year-old woman with chronic obstructive pulmonary disease, gastroesophageal reflux disease, Zenker’s diverticulum, chronic constipation, and prior spinal schwannoma presented after a mechanical fall with vertebral compression fractures and physiologic stress. She was discharged to her facility but returned the same day with coffee-ground emesis, dysphagia, and inability to tolerate secretions. Laboratory studies on admission showed leukocytosis and a gradual hemoglobin decline during hospitalization. Given her history and symptoms, a gastroenterologist was consulted, who performed esophagogastroduodenoscopy (EGD), which revealed extensive black, friable mucosa throughout the esophagus consistent with AEN. Biopsies showed ulceration, reactive atypia, and granulation tissue without evidence of malignancy. She was managed conservatively with keeping her nil per os (NPO), high-dose intravenous pantoprazole, intravenous fluids, and broad-spectrum antibiotics. Her condition improved gradually, and her diet was advanced to liquids and then pureed without complication. After discussion of her overall prognosis and functional decline, the patient and family elected for hospice care.

Conclusion: AEN is thought to result from a dual-hit mechanism involving ischemic injury and impaired mucosal defense from gastric reflux, typically presenting with hematemesis or coffee-ground emesis and diagnosed on EGD. Management is primarily supportive, including NPO status, acid suppression, fluid resuscitation, and treatment of underlying triggers. Antibiotics may be considered if any infection is suspected. Outcomes depend largely on the severity of comorbid illness rather than esophageal injury alone. This case emphasizes that AEN should be considered in frail elderly patients who develop upper gastrointestinal bleeding or dysphagia after acute physiologic stress, where early endoscopic diagnosis, conservative management, and timely goals-of-care discussions remain essential.

Figure or Table: Fig. A, B, C: Middle, distal, and proximal esophagus showing esophageal necrosis; D: Second part of duodenum showing distinct, well-defined circular folds (Kerckring's folds); E: Pinkish greater curvature of stomach without any signs of necrosis.