SHM Converge Scientific Abstract ePoster Gallery-An Unusual Case of Acute Esophageal Necrosis in the Setting of Euglycemic Diabetic Ketoacidosis

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This poster presents an unusual case of acute esophageal necrosis (AEN), or “black esophagus,” in a 58-year-old man with type 2 diabetes, insulin nonadherence, GERD, and daily alcohol use. He arrived with three days of severe epigastric pain and vomiting, preceded by two months of worsening nausea, early satiety, and a 30-pound weight loss. On admission he appeared dehydrated and tachycardic, with mild hyperglycemia, high anion gap metabolic acidosis, and elevated beta-hydroxybutyrate, leading to an initial diagnosis of diabetic ketoacidosis (DKA).<br /><br />Although his ketoacidosis improved with IV fluids and insulin, he continued to have severe abdominal pain. CT imaging showed distal esophageal and proximal duodenal wall thickening with marked gastric distention. Endoscopy then revealed diffuse black, ulcerated mucosa throughout the esophagus with exudate, plus multiple proximal duodenal ulcers, confirming AEN.<br /><br />The case highlights that AEN is usually associated with critical illness and hemodynamic instability, but it can also occur in noncritical settings such as DKA and alcohol intoxication. In this patient, several factors likely contributed: gastric outlet obstruction from duodenal ulcers, worsening reflux, poor oral intake, starvation, vomiting, dehydration, and underlying microvascular disease from diabetes. Even without frank shock, these conditions likely created enough ischemia and mucosal injury to cause esophageal necrosis.<br /><br />Treatment included strict NPO status, IV pantoprazole, and empiric antibiotics, followed by gradual diet advancement as symptoms improved. The poster emphasizes maintaining a broad differential diagnosis for diabetic patients with abdominal pain and ketones, especially when symptoms do not resolve as expected with DKA treatment.

Asset Subtitle

Eric Hirsch

Meta Tag

Author List Eric Hirsch, Nidhi Dhar

Category Clinical Vignettes

Concept Diabetic Ketoacidosis

Concept Acute Esophageal Necrosis

Concept Abdominal Pain

Concept Vomiting

Concept Differential Diagnosis

Distinguished Non-Finalist

Presenter Organization Montefiore Medical Center

Presenting Author Eric Hirsch

Track Adult

Keywords

acute esophageal necrosis

black esophagus

diabetic ketoacidosis

type 2 diabetes

esophagogastroduodenoscopy

gastric outlet obstruction

duodenal ulcers

gastroesophageal reflux disease

alcohol use

esophageal ischemia

Diabetic Ketoacidosis

Acute Esophageal Necrosis

Abdominal Pain

Vomiting

Differential Diagnosis