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Acute esophageal necrosis (black esophagus)

Daniel S Mishkin, MDCM, FASGE, FACG, AGAF
Daniel Gelrud, MD
Section Editor
Mark Feldman, MD, MACP, AGAF, FACG
Deputy Editor
Shilpa Grover, MD, MPH, AGAF


Acute esophageal necrosis, also known as black esophagus and necrotizing esophagitis, is a rare syndrome characterized by a striking diffuse circumferential black appearance of the esophageal mucosa that almost universally affects the distal esophagus and stops at the gastroesophageal junction [1-5].

This topic will review the epidemiology, clinical manifestations, diagnosis, and management of acute esophageal necrosis. The clinical manifestations, diagnosis, and management of other causes of esophagitis are discussed in detail, separately. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults" and "Medical management of gastroesophageal reflux disease in adults" and "Clinical manifestations and diagnosis of eosinophilic esophagitis" and "Treatment of eosinophilic esophagitis" and "Medication-induced esophagitis".)


Acute esophageal necrosis is rare with an estimated prevalence of up to 0.2 percent in autopsy series [6,7]. In endoscopy series, the prevalence of acute esophageal necrosis has ranged from 0.001 to 0.2 percent of cases [7-11]. The incidence of acute esophageal necrosis appears to be more than four times higher in men as compared with women, and patients have a mean age of 68 years at diagnosis [5,8,11].


The etiology of acute esophageal necrosis is unclear, but ischemia and gastric outlet obstruction may be inciting events [12-14]. In case reports, acute esophageal necrosis has been associated with broad spectrum antibiotic use, infections (eg, Candida albicans, cytomegalovirus, herpes virus, and Klebsiella pneumoniae), gastric volvulus, a paraesophageal hernia, hyperglycemia, diabetic ketoacidosis, an underlying malignancy, Stevens-Johnson syndrome, prolonged vomiting following alcohol binging, alcoholic hepatitis and lactic acidosis, and aortic dissection [8,11,15-26].

According to the "two hit" hypothesis, there is an initial event (ie, low flow vascular state), which then predisposes the esophageal mucosa to a severe topical injury (ie, by reflux of acid and pepsin). Gastric outlet obstruction leads to an accumulation of fluid in the stomach, which can promote esophageal reflux resulting in direct injury with necrosis. In support of this hypothesis is the observation that temporary reduction of esophageal blood flow can result in extensive esophageal necrosis, which resolves rapidly when flow is restored [27]. Furthermore, acute esophageal necrosis tends to occur in the distal third of the esophagus, which is relatively hypovascular compared with other esophageal segments. Finally, the necrosis of the esophageal mucosa and submucosa, microscopic thrombosis, and rapid recovery are similar to the changes seen in ischemic colitis. (See "Colonic ischemia", section on 'Diagnosis'.)

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Literature review current through: Sep 2017. | This topic last updated: Feb 06, 2017.
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  1. Moretó M, Ojembarrena E, Zaballa M, et al. Idiopathic acute esophageal necrosis: not necessarily a terminal event. Endoscopy 1993; 25:534.
  2. Brennan JL. Case of extensive necrosis of the oesophageal mucosa following hypothermia. J Clin Pathol 1967; 20:581.
  3. Obermeyer R, Kasirajan K, Erzurum V, Chung D. Necrotizing esophagitis presenting as a black esophagus. Surg Endosc 1998; 12:1430.
  4. Geller A, Aguilar H, Burgart L, Gostout CJ. The black esophagus. Am J Gastroenterol 1995; 90:2210.
  5. Gurvits GE, Cherian K, Shami MN, et al. Black esophagus: new insights and multicenter international experience in 2014. Dig Dis Sci 2015; 60:444.
  6. Etienne JP, Roge J, Delavierre P, Veyssier P. [Esophageal necrosis of vascular origin]. Sem Hop 1969; 45:1599.
  7. Postlethwait RW, Musser AW. Changes in the esophagus in 1,000 autopsy specimens. J Thorac Cardiovasc Surg 1974; 68:953.
  8. Lacy BE, Toor A, Bensen SP, et al. Acute esophageal necrosis: report of two cases and a review of the literature. Gastrointest Endosc 1999; 49:527.
  9. Augusto F, Fernandes V, Cremers MI, et al. Acute necrotizing esophagitis: a large retrospective case series. Endoscopy 2004; 36:411.
  10. Julián Gómez L, Barrio J, Atienza R, et al. [Acute esophageal necrosis. An underdiagnosed disease]. Rev Esp Enferm Dig 2008; 100:701.
  11. Ben Soussan E, Savoye G, Hochain P, et al. Acute esophageal necrosis: a 1-year prospective study. Gastrointest Endosc 2002; 56:213.
  12. Goldenberg SP, Wain SL, Marignani P. Acute necrotizing esophagitis. Gastroenterology 1990; 98:493.
  13. Jacobsen NO, Christiansen J, Kruse A. Incidence of oesophageal necrosis in an autopsy material. APMIS 2003; 111:591.
  14. Reichart M, Busch OR, Bruno MJ, Van Lanschot JJ. Black esophagus: a view in the dark. Dis Esophagus 2000; 13:311.
  15. Mangan TF, Colley AT, Wytock DH. Antibiotic-associated acute necrotizing esophagitis. Gastroenterology 1990; 99:900.
  16. Cattan P, Cuillerier E, Cellier C, et al. Black esophagus associated with herpes esophagitis. Gastrointest Endosc 1999; 49:105.
  17. Kram M, Gorenstein L, Eisen D, Cohen D. Acute esophageal necrosis associated with gastric volvulus. Gastrointest Endosc 2000; 51:610.
  18. Matsumoto N, Oki E, Morita M, et al. Successful treatment of acute esophageal necrosis caused by intrathoracic gastric volvulus: report of a case. Surg Today 2009; 39:1068.
  19. Mahé A, Kéita S, Blanc L, Bobin P. Esophageal necrosis in the Stevens-Johnson syndrome. J Am Acad Dermatol 1993; 29:103.
  20. Katsinelos P, Pilpilidis I, Dimiropoulos S, et al. Black esophagus induced by severe vomiting in a healthy young man. Surg Endosc 2003; 17:521.
  21. Endo T, Sakamoto J, Sato K, et al. Acute esophageal necrosis caused by alcohol abuse. World J Gastroenterol 2005; 11:5568.
  22. Kim YH, Choi SY. Black esophagus with concomitant candidiasis developed after diabetic ketoacidosis. World J Gastroenterol 2007; 13:5662.
  23. Yamauchi J, Mitsufuji S, Taniguchi J, et al. Acute esophageal necrosis followed by upper endoscopy and esophageal manometry/pH test. Dig Dis Sci 2005; 50:1718.
  24. Hwang J, Weigel TL. Acute esophageal necrosis: "black esophagus". JSLS 2007; 11:165.
  25. Săftoiu A, Cazacu S, Kruse A, et al. Acute esophageal necrosis associated with alcoholic hepatitis: is it black or is it white? Endoscopy 2005; 37:268.
  26. van de Wal-Visscher E, Nieuwenhuijzen GA, van Sambeek MR, et al. Type B aortic dissection resulting in acute esophageal necrosis. Ann Vasc Surg 2011; 25:837.e1.
  27. Haviv YS, Reinus C, Zimmerman J. "Black esophagus": a rare complication of shock. Am J Gastroenterol 1996; 91:2432.
  28. Gurvits GE, Shapsis A, Lau N, et al. Acute esophageal necrosis: a rare syndrome. J Gastroenterol 2007; 42:29.
  29. Gurvits GE, Robilotti JG. Isolated proximal black esophagus: etiology and the role of tissue biopsy. Gastrointest Endosc 2010; 71:658.
  30. Neumann DA 2nd, Francis DL, Baron TH. Proximal black esophagus: a case report and review of the literature. Gastrointest Endosc 2009; 70:180.
  31. Sharma SS, Venkateswaran S, Chacko A, Mathan M. Melanosis of the esophagus. An endoscopic, histochemical, and ultrastructural study. Gastroenterology 1991; 100:13.
  32. Ohashi K, Kato Y, Kanno J, Kasuga T. Melanocytes and melanosis of the oesophagus in Japanese subjects--analysis of factors effecting their increase. Virchows Arch A Pathol Anat Histopathol 1990; 417:137.
  33. Berry MA, DiPalma JA. Esophageal melanosis. J Clin Gastroenterol 1995; 21:79.
  34. Kimball MW. Pseudomelanosis of the esophagus. Gastrointest Endosc 1978; 24:121.
  35. Guzman RP, Wightman R, Ravinsky E, Unruh HW. Primary malignant melanoma of the esophagus with diffuse melanocytic atypia and melanoma in situ. Am J Clin Pathol 1989; 92:802.
  36. DiCostanzo DP, Urmacher C. Primary malignant melanoma of the esophagus. Am J Surg Pathol 1987; 11:46.
  37. Hulshof MC, Van Haaren PM, Zum Vörde Sive Vörding PJ, et al. Radiotherapy combined with hyperthermia for primary malignant melanomas of the esophagus. Dis Esophagus 2010; 23:E42.
  38. Kozlowski LM, Nigra TP. Esophageal acanthosis nigricans in association with adenocarcinoma from an unknown primary site. J Am Acad Dermatol 1992; 26:348.
  39. Ramirez-Amador V, Esquivel-Pedraza L, Caballero-Mendoza E, et al. Oral manifestations as a hallmark of malignant acanthosis nigricans. J Oral Pathol Med 1999; 28:278.
  40. Khan HA. Coal dust deposition--rare cause of "black esophagus". Am J Gastroenterol 1996; 91:2256.
  41. Nayyar AK, Royston C, Slater DN, Bardhan KD. Pseudomembranous esophagitis. Gastrointest Endosc 2001; 54:730.
  42. Gurvits GE. Black esophagus: acute esophageal necrosis syndrome. World J Gastroenterol 2010; 16:3219.
  43. Gelrud D, Noyer C, Brenner S, Brandt LJ. Clinical outcomes of acute necrotizing esophagitis (abstract). Am J Gastroententerol 2000; 95:34.