1377 Gastric Necrosis Associated With Necrotizing Pancreatitis

Abstract

INTRODUCTION: Acute pancreatitis may lead to local complications and systemic toxicity. Gastric necrosis is a rare complication with only few cases reported in the literature. Herein we present a case of severe acute necrotizing pancreatitis acute complicated by gastric necrosis. CASE DESCRIPTION/METHODS: Our patient is a 42-year-old male with a history of idiopathic recurrent necrotizing pancreatitis who presented with severe epigastric abdominal pain, nausea and vomiting. Previous imaging revealed pancreatic necrosis in the body and head of the pancreas and extensive splanchnic thrombosis. Labs showed normal blood count, lipase and complete metabolic panel. CT of the abdomen during this admission revealed large volume ascites and total pancreatic necrosis and multiple areas of low attenuation in the expected location of the pancreatic head and body (Figure 1). Despite supportive care and antibiotics, he was unable to tolerate oral intake. On day 14 he developed hematemesis and hypotension. His hemoglobin dropped to 9.3 g/dL from 13.3 g/dL. An abdominal x-ray revealed a curvilinear lucency overlying the left lateral upper stomach suggestive of gastric pneumatosis. Upper endoscopy showed erythema, edema, and severe ulcerations with black necrotic mucosa in the inferior and posterior walls of the stomach. The anterior wall was relatively spared with clear demarcation of ischemic and viable mucosa (Figure 2). Gastric biopsies confirmed gastric necrosis. The patient's hemodynamic status worsened, and he required vasopressor support. Further interventions were deferred given his comorbidities and worsening hemodynamic status, and he was discharged to hospice care. DISCUSSION: Gastric necrosis is a rare complication of acute pancreatitis and occurs due to severe reduction in gastric mucosal blood flow. This can be secondary to thrombosis of large vessels such as the celiac trunk or attributed to microcirculatory vasospasm due to the release of thrombogenic and inflammatory mediators. The development of gastric necrosis leads to further clinical deterioration in a clinically ill patient. Despite its rarity, gastric necrosis should be suspected in the setting of severe pancreatitis in patients with signs of gastrointestinal bleeding and clinical deterioration.