A Rare Case of Severe Ischemic Gastropathy Causing Upper GI Bleed

Abstract

Ischemic gastropathy is an uncommon diagnosis due to the extensive arterial collaterals that supply the stomach. Hence, its diagnosis is infrequently entertained in patients presenting with upper GI bleed. A 76 year-old woman with hypertension, hyperlipidemia, and chronic kidney disease presented with acute onset shortness of breath. She was tachycardic, tachypneic, and hypotensive. On exam she had rales, expiratory wheezes, and abdominal distention. Labs showed elevated lactate of 3.27 mmol/L, metabolic acidosis, leukocytosis of 22 K/uL, and normal hemoglobin. She was managed for acute hypoxemic respiratory failure and sepsis secondary to pneumonia. Despite treatment of her sepsis, lactic acidosis persisted > 2mmol/L. An abdominal CT was obtained to evaluate distention showed pneumatosis intestinalis. IV metronidazole was started to treat gas forming organisms, with an immediate improvement in WBC from 24 to 8.6 K/uL. There were episodes of melena requiring a total of 9 units of PRBCs. EGD was done and showed extensive shallow ischemic ulcers involving most of the anterior gastric wall and denuded duodenal mucosa. Subsequent CT angiography of the abdomen showed severe atherosclerotic plaques causing focal high grade stenosis at the celiac axis and lesser stenosis of the superior mesenteric artery, and complete resolution of pneumatosis intestinalis. An IR guided stent was placed across the celiac with successful reperfusion confirmed by fluoroscopy. Serum lactate levels rapidly normalized and a repeat EGD three weeks later showed near complete resolution of the gastric ulcers.2679_A Figure 1. Pneumatosis intestinalis.2679_B Figure 2. Large ischemic gastric ulcers.2679_C Figure 3. Healing ischemic gastric ulcers s/p stent placement.Gastric ischemia may be secondary to systemic hypoperfusion in the setting of shock or local splanchnic vessel stenosis or thrombosis. Ischemia leads to gastric mucosal barrier dysfunction, accumulation of gastric acid, and subsequent ulceration. Our patient had episodes of global hypoperfusion as well as local atherosclerosis. She was also on intermittent hemodialysis, which has been shown to cause accelerated rates of atherosclerosis. Ischemic gastropathy is a rare cause of upper GI bleeding. Hence, it is important to consider in patients with persistent lactic acidosis and non-healing gastric ulcers despite proton pump inhibitors. While ischemia secondary to transient low flow states may be managed conservatively with bowel rest and broad spectrum antibiotics, definitive recanalization of the celiac trunk may be required when high grade stenosis is present.