Necrotizing Oesophagitis Associated with Ketoacidosis: A Case Series Exploring the Diagnostic Dilemma of Metabolic Overlap Syndromes.

Background: Necrotizing esophagitis, or acute esophageal necrosis (AEN), is a rare but serious cause of upper gastrointestinal bleeding, typically associated with critical illness. While traditionally linked to hypoperfusion states, its occurrence in metabolic emergencies-particularly where diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA), and starvation ketosis overlap-remains underrecognized. Materials and methods: We present a case series of four patients admitted to a rural Indian hospital with upper gastrointestinal bleeding in the setting of severe metabolic derangement, all diagnosed with AEN on upper gastrointestinal endoscopy. Results: Case 1 involved a patient with type 2 diabetes and chronic alcohol use presenting an "overlap syndrome" with extreme lactate elevation (11.6 mmol/L), biochemical pancreatitis (lipase 534 IU/L), and normal ultrasound. Case 2 demonstrated "pseudo-DKA" with normal glycated hemoglobin (HbA1c) (5.9%) and acute pancreatitis [lipase 1,946 IU/L, computed tomography (CT)-confirmed]. Case 3 represented a "cytokine tsunami" with thyroid storm, DKA, and multi-drug resistant (MDR) sepsis culminating in grade D necrotizing esophagitis. Case 4 illustrated "two hits from the same bottle"-AKA with portal hypertensive gastropathy (PHG). All patients improved with conservative management. No deaths occurred. Conclusion: Acute esophageal necrosis should be considered when upper GI bleeding complicates ketoacidosis. The underlying etiology is often multifactorial, requiring clinicians to look beyond simple diagnostic labels. Recognizing distinct clinical patterns-overlap syndromes, pseudo-DKA, cytokine storms, and dual alcohol-related pathologies-may aid in early diagnosis and severity assessment in resource-limited settings.