Roger Williams Medical Center Providence, RI, United States
Kanwal Bains, MD1, Breton Roussel, MD2, Marc Vecchio, MD3, Amanda Pressman, MD3 1Roger Williams Medical Center, Providence, RI; 2Warren Alpert School of Medicine, Brown University, Providence, RI; 3Warren Alpert Medical School of Brown University, Providence, RI
Introduction: Gas within the gastric wall is an uncommon finding on imaging studies. When present, one should consider gastric ischemia or emphysematous gastritis.
Case Description/Methods: The patient is a 77 year old male with a history of coronary disease and prior MI in 2015, on aspirin and clopidogrel, end stage renal disease on hemodialysis, extensive peripheral vascular disease and insulin dependent diabetes who presented with several days of frank melena, shortness of breath, and lethargy. Physical exam was notable for hypotension and abdominal tenderness. Labs were significant for a lactate of 6.3, hemoglobin of 8.3 g/dL, and blood cultures positive for coagulase negative staphylococci. He was initially given intravenous fluids, blood transfusion and broad-spectrum antibiotics. The patient underwent upper endoscopy (EGD), which showed four bleeding angioectasias along with an oozing gastric ulcer, which were cauterized and clipped. The exam otherwise showed normal gastric mucosa. The patient’s hemodynamic status and hemoglobin subsequently stabilized and clopidogrel was held. However, 13 days following the initial EGD the patient experienced abdominal pain and an episode of small volume hematemesis prompting repeat EGD. The repeat EGD revealed extensive dusky and ulcerated mucosa extending along the gastric body to antrum. CTA of abdomen and pelvis revealed splenic infarct, right gastric artery thrombus, portal vein gas, and gastric wall edema with emphysema. Transthoracic and transesophageal echocardiography did not elucidate an embolic source. The patient was managed medically with bowel rest, aspirin, and total parenteral nutrition (TPN). After resuming an enteral diet, the patient was discharged home on IV antibiotics.
Discussion: In our patient, ischemia from arterial thrombus was likely the inciting nidus for gastric ischemia. The abrupt change in the patient’s endoscopic exam and clinical status, along with imaging evidence of gastric artery thrombus and splenic infarct support an embolic event which precipitated gastric ischemia. Gastric ischemia remains a rare condition given abundant gastric collateralization. Emphysematous gastritis, a rare and often fatal form of gastritis caused by infection of the stomach wall by gas forming bacteria was also considered as an etiology. Management for both conditions involve resuscitation, parenteral nutrition, and intravenous broad-spectrum antibiotics. Surgery is often reserved for gastric perforation.
Figure: a: Gastric ulcer at fundus seen on day 1 of hospitalization. b: EGD showing dusky and ulcerated mucosa extending from gastric body to antrum seen on day 14 c: CTA Abd/pelvis showing arrows pointing to air in stomach wall along with gas in portal vein on day 14
Disclosures: Kanwal Bains indicated no relevant financial relationships. Breton Roussel indicated no relevant financial relationships. Marc Vecchio indicated no relevant financial relationships. Amanda Pressman indicated no relevant financial relationships.
Kanwal Bains, MD1, Breton Roussel, MD2, Marc Vecchio, MD3, Amanda Pressman, MD3. P3131 - A Successfully Medically Managed Case of Gastric Emphysema from Gastric Artery Embolism, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.