The two-hit hypothesis in acute esophageal necrosis: black esophagus in severe atherosclerosis and untreated gastroesophageal reflux disease: a case report

This case highlights an atypical, nonbleeding presentation of acute esophageal necrosis and reinforces the importance of maintaining clinical suspicion even in the absence of classic symptoms. It underscores the relevance of the "two-hit" hypothesis, where ischemic insult and impaired mucosal defense act synergistically to cause esophageal necrosis. Timely endoscopic evaluation and early initiation of appropriate therapy led to favorable outcomes in this high-risk patient. Increased awareness of such presentations can aid in earlier diagnosis and reduce the high morbidity and mortality associated with acute esophageal necrosis.