'Black esophagus' in a case of candidial gastric perforation

‘Black esophagus’or acute esophageal necrosis is a rare condition, frequently affecting the distal esophagus with a sharp transition to normal-appearing mucosa at the gastroesophageal junction. It is characterized by circumferential blackish discoloration and necrosisof the mucosa due to severe hemodynamic compromise.The pathogenesis of black esophagus is unclear, but a “two-hit” hypothesis for a dominant mucosal necrosis has been described - a low-flow vascular setting followed by an altered reparative ability of the mucosal barrier systems. The etiology is usually multifactorial, triggered by an acute event. It is associated with a high mortality rate of 31.8%−50%, most of the deaths caused by underlying illnesses. Mortality specific to acute esophageal necrosis is approximately 6%.We report a case of 72-year-old hypertensive male patient presenting with perforated gastric ulcers and sepsis. Distal gastrectomy revealed two candidial perforations. Patient expired on second post- operative day. Autopsy revealed a diffuse circumferential blackish discoloration of distal one third of the esophageal mucosa abruptly stopping at the gastro esophageal junction. On microscopy, the esophageal mucosa was ulcerated, and covered by necro-inflammatory exudate and blackish pigment extending upto the muscularis propria. Many submucosal vessels showed fresh fibrin thrombi. Special stains for fungus were negative. The diagnosis of black esophagus or acute esophageal necrosis was made. Other findings included fungal peritonitis, ischemic heart disease and chronic pyelonephritis with right-sided nephrolithiasis. The cause of death was related to septicaemia.