From the *LUNAM University; Departments of †Forensic Science, ‡Visceral Surgery, and §Pathology, Angers University Hospital; and ∥INSERM, U922 Faculty of Medicine, Angers, France.
Manuscript received January 25, 2012; accepted July 30, 2012.
The authors report no conflicts of interest.
Reprints: Nathalie Jousset, MD, Department of Forensic Medicine, Angers University Hospital, 4 rue Larrey, 49933 Angers Cedex 9, France. E-mail: NaJousset@chu-angers.fr.
Black esophagus, also known as acute esophageal necrosis, is an uncommon but often fatal pathology. For the coroner, diagnosis could be easily given during the autopsy via simple macroscopic search. However, because of its low incidence (between 0.01% and 0.28% in clinical practice),1–4 it is seldom considered.
All physicians should be aware of this diagnosis, in turn allowing the deceased to be returned promptly to their loved ones.
An elderly man (age, 80 years) who lived alone was found dead in his garden, lying face down. His body was discovered by the cleaner, and no information was available as to his prior medical or surgical history.
A forensic examination was performed by a forensic examiner at the spot where the body was discovered. Death was estimated to have occurred between 12 and 48 hours earlier. This examination revealed signs of excoriation on the knees and scalp. No other injuries were noted, and there was no blood found at the scene. Once the examination had been completed, an autopsy was recommended.
The autopsy was performed at the forensic institute on the day after the body’s discovery. External examination confirmed the previous day’s findings. There were some superficial wounds to the knees. Dissection of the cervicocephalic area did not reveal any recent trauma.
Examination of the thorax uncovered a fracture of the fifth rib to the left and 2 hemorrhagic infiltrations. The lungs were examined from a macroscopic viewpoint, and congestion was observed. An examination of the heart did not present anything significant macroscopically. A histologic examination of both organs was recommended, which showed a little more than calcific stenosis of the aortic valve and a left ventricular hypertrophy. Coronay arteries were affected by atherosclerosis that made some stenosis less important than 50% of the diameter.
Macroscopic examination of the esophagus revealed that the mucosa along its full length was black, an unusual occurrence (Fig. 1). A histologic examination was carried out and concluded that total necrosis of the esophageal mucosa had occurred. The mucosa had been replaced by a fibrino-leucocytar substance. This substance was on a lymphoid infiltration. In some places, the necrosis had reached the muscularis propria. The remainder of the wall was found to be the place of very rare inflammation areas (Fig. 2, A and B).
Concerning the abdomen, a macroscopic examination of the stomach revealed erosive gastritis of the mucosa. In it was 150 mL of digestive liquid that was black. There was no blood in the gastrointestinal tract.
With histologic help, the autopsy was able to conclude that death had occurred because of black esophagus.
Black esophagus, also known as acute esophageal necrosis syndrome, is very rare. Its incidence is reportedly between 0.01% and 0.28% in large endoscopic series1–4 and between 0% and 0.2% in large autopsy series.5,6 In vivo, this pathology is linked to endoscopic examination.7 To our knowledge, just 3 articles have been published in forensic reviews about this cause of sudden death.8–10
Risk factors include old age (older than 67 years), male sex, cardiovascular pathology, gastric obstruction, hemodynamic instability, alcohol, malnutrition, diabetes mellitus, renal insufficiency, hypoxia, hypercoagulation, trauma, and infection by Lactobacillus acidophilus or herpes simplex or Candida albicans.7,11 Nevertheless, its pathophysiology is as yet unknown.
In this case, the man was 80 years old and probably an alcoholic (this can be presumed because of his lifestyle and the multitude of different bottles found in the house). Unfortunately, we have no more information about his medical history.
For gross pathology, the color is characteristic. A black color was observed along the full length of the esophageal mucosa, suddenly stopping at the gastroesophageal junction.8,9 In this case, histology served to confirm the diagnosis.
Esophageal necrosis was linked with the macroscopic nature of erosive gastritis. This linkage, or that of a duodenal ulcer, had previously been described in some reports,9,12 meaning that we could consider diffuse vascular injuries, such as diffuse ischemia.
This pathology is complex. In fact, the vascular supply to the esophagus is rich, coming from major arteries and separated into 3 parts: the upper, middle, and distal esophagus.12 As a result, it is very difficult to explain the appearance of necrosis along the full length of the mucosa.
One of the presumed causes of death is massive blood loss due to esophageal mucosa necrosis.8 Another report considered the cause of death to be cardiac arrhythmia linked to collapse and the Valsalva maneuver in a case of sudden death attributed to black esophagus.10
It is considered that black esophagus can be the direct cause or can contribute to death.8 Death is frequent for this pathology, with an assessed mortality rate of between 30% and 36%.7,11
The direct cause of death in our case is unclear. We can only suppose, in the context of sudden death without prodroma, that this cause might be attributed to fatal cardiac arrhythmias secondary to cellular ischemia and lysis causing hyperkalemia.
In forensic practice, some differential diagnoses exist, such as burning after toxic ingestion (caustic esophagitis). This coloration can also be seen in malignant melanoma of the esophagus, in acanthosis nigricans, and in anthracosis.8
Though rare, this pathology is often fatal. The black color of all the esophageal mucosa is characteristic of the pathology and should alert the forensic examiner to a potential diagnosis of black esophagus.
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