Non-operative management of a black esophagus associated with perforated gastric ulcer: A case report and literature review

Introduction: Acute esophageal necrosis (AEN), or black esophagus, is a rare condition typically observed in critically ill patients. While esophageal perforation is a known complication, the coexistence of AEN with a perforated gastric ulcer has not been previously reported. Surgical management is standard in such cases due to the risk of rapid deterioration. Case report: We report the case of a 67-year-old male with multiple comorbidities, admitted for acute respiratory failure and treated in the intensive care unit. He developed hemorrhagic and septic shock secondary to AEN, with active bleeding at the cardia. Endoscopy confirmed black esophagus. A subsequent CT scan showed pneumoperitoneum and perigastric fat stranding, consistent with a perforated gastric ulcer. Despite recurrent bleeding, the patient was managed conservatively, with intravenous proton pump inhibitors, octreotide for bleeding control, broad-spectrum antibiotics, transfusions, and close clinical and radiological monitoring. No nasogastric tube was used due to esophageal necrosis. Endoscopy was repeated for hemostatic therapy and showed progressive mucosal improvement. Anticoagulation was safely resumed. The patient improved and was discharged without surgery. Discussion: Although surgical treatment is typically required in gastrointestinal perforations, especially when associated with AEN, our case demonstrates that a carefully selected patient can be managed non-operatively. The decision was based on clinical stability, imaging findings, and multidisciplinary consensus. Conclusion: This is the first reported case of AEN associated with a perforated gastric ulcer successfully treated without surgery. It suggests that non-operative management may be considered in select cases under close supervision.