black esophagus , is a rare multifactorial condition , characterized by endoscopic images of diffuse , circumferential black mucosal discoloration in the distal esophagus that stops abruptly at the gastroesophageal junction . the most common clinical presentation ( 90% ) is acute upper gi bleeding and this represents a diagnostic challenge . the authors report a case of a patient with acute esophageal necrosis ( aen ) developed after pancreatic resection surgery . laboratory investigation and radiological imaging revealed a neoplasia of the ampulla of vater not amenable to removal by endoscopic techniques . laboratory investigations detected anemia and an esophagogastroduodenoscopy ( egd ) showed a circumferentially black - appearing mucosa at the inferior third of the esophagus ( fig . the gastro - jejunal anastomosis was pervious to the passage of the instrument and no biopsies were performed . subsequent computed tomography ( ct)-scan revealed thickness of the wall of middle and inferior esophagus with a reduction of vascularization . the patient was treated with hemotransfusion , total parenteral nutrition and high - dose proton pump inhibitor ( ppi ) . another egd was performed a week later and revealed a complete esophageal re - epithelization ( fig . however , the disease may be underestimated due to the subtle clinical presentation and the healing properties of esophageal mucosa . men are four times more commonly affected than women and the peak incidence occurs at the sixth decade of life . the most important are tissue hypoperfusion , altered gastric motility with acid reflux , impaired local barrier defenses associated with decrease of metabolic reserves [ 2 , 3 ] . aen may arise in the setting of hemodynamic shock , diabetes , vascular disease , thromboembolic phenomena , sepsis , immunosoppression , chronic diseases , alcohol abuse , malnutrition , multiple organ failure , recent surgery , tumors , gastric volvulus and ketoacidosis . the most frequent clinical presentation ( 90% ) is upper gastrointestinal bleeding with hematemesis and melena . other symptoms include abdominal pain , dysphagia , nausea , fever and syncope [ 2 , 4 ] . laboratory tests may show anemia and leukocytosis and ct scan can reveal thickening of distal esophagus , stomach distension and a possible obstruction to gastric emptying . egd is essential to diagnose the disease documenting diffuse , circumferential black mucosa which abruptly stops in the z - line . it has been proposed an endoscopic staging of the disease : pre - necrotic esophagus ( stage 0 ) , black esophagus ( stage 1 ) ,  chess - board esophagus ( stage 2 ) and re - epithelized esophagus ( stage 3 ) . differential diagnosis includes malignant melanoma , acanthosis nigricans , corrosive agents ingestion and infectious diseases . possible complications are perforation , esophageal stenosis and stricture formation , microbial superinfection which can lead to mediastinitis and abscess formation . therapeutic approaches consist of treating underlying conditions with fluid resuscitation , nil - per - os , total parenteral nutrition and intravenous ppis or histamine receptor blocker . the use of naso - gastric tube is not recommended due to the risk of perforation . antimicrobial therapy should be reserved to the patients with suspected esophageal perforation , sepsis or impaired immune function . surgical treatment is to perform only with a perforated esophagus with mediastinitis or abscess formation and for the treatment of the late esophageal stricture . prognosis of black esophagus is poor with a mortality rate of 32% and it depends on underlying illnesses even if deaths secondary to esophageal necrosis occur in < 6% of cases . marta bonaldi and corrado sala were involved in the clinical management of the patients and drafted the manuscript . giorgio fratus , pierpaolo mariani and lorenzo novellino were involved in the surgical and clinical management of the patients and reviewed the manuscript .
abstractblack esophagus is a rare , multifactorial disease . a case of acute black esophagus following pancreatic resection 
 is presented . 
 the patient referred us with a specific gastrointestinal bleeding . 
 an esophagogastroduodenoscopy confirmed the diagnosis . 
 we performed conservative treatment with complete esophageal re - epithelization and negative follow - up for stenosis or necrosis relapse .