Ischemic Gastritis

Abstract

The abundant vascular supply of oxygenated blood to the stomach via major arteries and smaller collateral vessels provides resistance to mucosal ischemia. However, mucosal changes can occur in the acute vaso-occulsive setting after a major operative procedure, or with chronic mesenteric insufficiency. We present a patient who developed diffuse gastric ischemia one day after coronary bypass surgery during a one month hospitalization for a global ischemic event. A 67 year-old female developed bright red blood output from her oral-gastric tube one day after coronary bypass surgery using a saffenous vein graft. Her bowel movements were loose and without hematochezia. She had no prior history of GI bleeding. She was initially hospitalized one month prior to the surgery for non-ST elevation myocardial infarction and cardiogenic shock with associated elevation of liver transaminases and acute renal failure. She was treated with aspirin, prophylactic esomeprazole, and vasopressors during her hospital course. She had a history of atherosclerotic disease and smoked tobacco regularly. She was intubated and sedated, with mean arterial blood pressure 81 mmHg and central venous pressure 9 cmH2O. Examination demonstrated hypo-active bowel sounds and a soft abdomen. Hemoglobin was 10.6 g/dL, pH 7.46, lactic acid 1.8 mmol/L, and stool was hemoccult negative. EGD revealed severe ulceration and friability throughout the entire gastric mucosa, with a normal esophagus and duodenum. Gastric biopsies demonstrated diffuse mucosal necrosis with preservation of only 1/3 of the mucosa, consistent with ischemia. Colonoscopy was normal. Conservative medical management was provided with an intravenous proton pump inhibitor and TPN. Five days later, she was extubated and began a liquid diet without complication. She was discharged from the hospital one week later. Mesenteric ischemia of the small and large bowel are more commonly investigated than the stomach. Gastric ischemia can be quite severe and in the presence of necrosis causes significant morbidity. A common diagnostic and treatment modality is surgery. Prior reports demonstrate either an acute or chronic etiology. We present a rare patient with ischemic gastritis and mucosal necrosis secondary to both acute and chronic injury, successfully treated with medical therapy. We conclude that certain circumstances are amenable to a conservative treatment approach.