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Black esophagus. (Original Article).


Black esophagus is a rare, relatively newly described, and usually incidental finding. The differential diagnosis includes several disease states, including ischemia, which has been implicated in acute necrotizing esophagitis. Several theories have been proposed to explain its etiology.


Black esophagus is an unusual incidental finding on esophagoscopy that first came to light in 1990. (1-3) Endoscopy will detect a diffuse blackening of the esophagus that ends abruptly at the transitional line of the esophagogastric junction (figure).

The differential diagnosis of black esophagus includes ischemic necrosis of the esophagus, exogenous and endogenous pigmentation, and hypersensitivity-related mucosal reactions. Coal dust deposition (4) and mucosal tattooing of the esophagus following the administration of activated charcoal (5) have also been reported. Increased melanogenesis (melanosis esophagi) may be another cause that appears to be related to chronic esophagitis. (6) Malignant melanoma, a rare occurrence in the esophagus, should be considered in the differential diagnosis. (7) Infections that can cause blackening of the esophageal mucosa include Canadida (8) and herpes (9) infections. Finally, acanthosis nigricans can manifest in this way, usually in association with gastric adenocarcinoma. (10) Ischemia appears to be implicated as the primary etiology in acute necrotizing esophagitis. (1,11)

Necrotizing esophagitis

Underlying conditions that are believed to predispose patients to an ischemic black esophagus include coronary and peripheral vascular diseases, low flow states (e.g., shock), gastric volvulus, gastric-outlet obstruction, pancreatitis, cancer, acute fatty liver of pregnancy, overwhelming infection, severe hypothermia, severe emesis, herpes infection, nasogastric-tube trauma, and hyperglycemia (particularly in diabetic ketoacidosis). (12) Moreover, a hypersensitivity reaction to antibiotic therapy has been proposed as a possible cause of acute necrotizing esophagitis manifesting as black esophagus. (13)

Esophageal necrosis has also been reported to occur in Stevens-Johnson syndrome. (14) Alendronate use by osteoporotic patients has been associated with a severe erosive esophagitis. (15) Finally, ingestion of strong alkaline substances (e.g., lye) can also cause a dark discoloration of the esophageal mucosa following coagulative necrosis.

A biopsy is required to help establish a diagnosis. Tissue in these cases must be obtained with caution because necrosis might extend deep into the muscular layers, which can increase the risk of iatrogenic perforation.


(1.) Goldenberg SP, Wain SL, Marignani P. Acute necrotizing esophagitis. Gastroenterology 1990;98:493-6.

(2.) Geller A, Aguilar H, Burgart L, Gostout CJ. The black esophagus. Am J Gastroenterol 1995;90:2210-12.

(3.) Katsinelos P, Christodoulou K, Pilpilidis I, et al. Black esophagus: An unusual finding during routine endoscopy. Endoscopy 2001;33:904.

(4.) Khan HA. Coal dust deposition--rare cause of "black esophagus" [letter]. Am J Gastroenterol 1996;91:2256.

(5.) Lopes de Freitas JM, Ferreira MG, Brito MJ. Charcoal deposits in the esophageal and gastric mucosa. Am J Gastroenterol 1997;92:1359-60.

(6.) Sharma SS, Venkateswaran S, Chacko A, Mathan M. Melanosis of the esophagus. An endoscopic, histochemical, and ultrastructural study. Gastroenterology 1991;100:13-16.

(7.) Takubo K, Kanda Y, Ishii M, et al. Primary malignant melanoma of the esophagus. Hum Pathol 1983:14:727-30.

(8.) Wilcox CM, Schwartz DA. Endoscopic-pathologic correlates of Candida esophagitis in acquired immunodeficiency syndrome. Dig Dis Sci 1996;41:1337-45.

(9.) Cattan P, Cuilerier E, Cellier C, et al. Black esophagus associated with herpes esophagitis. Gastrointest Endosc 1999;49:105-7.

(10.) Kozlowski LM, Nigra TP. Esophageal acanthosis nigricans in association with adenocarcinoma from an unknown primary site. J Am Acad Dermatol 1992;26(Pt 2):348-51.

(11.) Haviv YS, Reinus C, Zimmerman J. "Black esophagus": A rare complication of shock. Am J Gastroenterol 1996;91:2432-4.

(12.) De Langle C, Cadiot G, Calvat S, et al. [Two cases of "black esophagus" discovered during severe diabetic ketoacidosis]. Gastroenterol Clin Biol 1994:18:176-7.

(13.) Mangan TF, Colley AT, Wytock DH. Antibiotic-associated acute necrotizing esophagitis [letter]. Gastroenterology 1990;99:900.

(14.) Mahe A, Keita S, Blanc L, Bobin P. Esophageal necrosis in the Stevens-Johnson syndrome. J Am Acad Dermatol 1993:29:103-4.

(15.) Abraham SC, Cruz-Correa M, Lee LA, et al. Alendronate-associated esophageal injury: Pathologic and endoscopic features, Mod Pathol 1999;12:1152-7.

(16.) Poelman JR, Hausman RH, Hoitsma HF. Endoscopy in lye burns of oesophagus and stomach. Endoscopy 1977;9:172-7.

(17.) Howell JM. Alkaline ingestions. Ann Emerg Med 1986;15:820-5.

From the Department of Pathology (Dr. Pantanowitz and Dr. Nasser) and the Department of Gastroenterology (Dr. Gelrud), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.

Reprint requests: Liron Pantanowitz, MD, Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215. Phone: (617) 667-4344; fax:(617)667-7120; e-mail:
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Article Details
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Author:Nasser, Imad
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Jun 1, 2003
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