Moribund Stomach

Abstract

Question: A 75-year-old Caucasian man sustained traumatic rib fractures with right-sided pneumothorax and right hip fracture after falling off a ladder. He underwent tube thoracostomy and repair of his hip fracture, and was doing relatively well until he suffered cardiopulmonary arrest 4 days later. He was successfully resuscitated after about 15 minutes and transferred to the intensive care unit. Mechanical ventilation and vasopressor support was required postresuscitation. Before cardiopulmonary arrest, there was no documented evidence of hypotension or tachycardia, and the triggering event was considered to be aspiration with attendant respiratory failure. It was discovered that the patient had a significant, 3-g decline in his hemoglobin over the preceding 24 hours, associated with some coffee-ground output from the nasogastric tube. The patient underwent emergent esophagogastroduodenoscopy (Supplementary Videos 1 and 2). He was found to have severe ulcerative esophagitis. There was no evidence of active bleeding. There was loss of normal mucosal vascular pattern throughout the entire stomach, and multiple diminutive ulcers and subepithelial hemorrhage, noted in the proximal and mid corpus (Figure A, B). Examination of the duodenum up to the third portion revealed diffuse patchy mucosal erythema. What is the diagnosis explaining these endoscopic findings? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The endoscopic findings are consistent with acute and diffuse ischemic insult due to the low-flow state resulting from the patient's cardiopulmonary arrest and persistent shock. In this patient, the low-flow state likely persisted for some time after resuscitation given the need for multiple vasopressors. Clinical ischemia of the stomach is very rare in view of its rich vascular supply and intramural anastomoses. It has been shown that both arterial and venous circulation must be compromised before gastric ischemia ensues.1Abdu R.A. Garritano D. Culver O. Acute gastric necrosis in anorexia nervosa and bulimia Two case reports.Arch Surg. 1987; 122: 830-832Crossref PubMed Scopus (96) Google Scholar Lee et al2Lee T.C. Lin J.T. Liang C.W. et al.Ischemic gastropathy: leopard skin in the stomach.Endoscopy. 2005; 37: 927Crossref PubMed Scopus (6) Google Scholar have previously reported ischemic gastropathy on endoscopy performed after cardiac arrest. Most other cases of gastric ischemia reported in the literature have been in the setting of acute massive gastric dilatation, either in the setting of gastric volvulus or binge eating associated with primary eating disorders.1Abdu R.A. Garritano D. Culver O. Acute gastric necrosis in anorexia nervosa and bulimia Two case reports.Arch Surg. 1987; 122: 830-832Crossref PubMed Scopus (96) Google Scholar Increased intragastric pressure >20 cm H2O, which exceeds venous pressure, results in gastric mucosal ischemia and necrosis.3Edlich R.F. Borner J.W. Kuphal J. et al.Gastric blood flow Its distribution during gastric distention.Am J Surg. 1970; 120: 35-37Abstract Full Text PDF PubMed Scopus (43) Google Scholar The predominantly mid corpus distribution of ischemic ulcerations in this case is likely explained by the watershed area of gastric vascular supply. Hemodynamic instability during esophagogastroduodenoscopy precluded us from obtaining biopsies. This patient had increasing intra-abdominal pressure as confirmed by increasing bladder pressures, and an emergent laparotomy was undertaken. The patient was found to have extensive ischemic changes involving the gastrointestinal tract as well as other intra-abdominal viscera, further corroborating an ischemic etiology from a low-flow state as the explanation for these rare endoscopic findings. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlOTgwNDI3NjJjMGIwZDA1NDJlYWVkZDliN2U3NTg2ZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgxMjM3MjAyfQ.g2MPoxwS8j4vCybyxrQqE4z1baeTznOcJYrZ8JTooBo7slmg_dpz8iVBioS-U3Ut4xyif46aqf5Dygdh0Q_TMJVnV2QNsPG4XtiXgoGfHrIvasOUJ8AGwnQpsN5FHf25GXg9JG8VHy2MXbgc6vjXJAVvAuNRbd7hoJ6XHAGvGO8Z4HxsJ80LKYzUuj1fffkS0Cu2EkEvhEwJDQPps3JBtmpvAiODiwsSnd6IzlKrBUZVMHrJ_bxlwwqHVLY-a6rEUc6Lj16NfuZ46VvzfbLD6-vUrrrGz72_zIetKTtJ2F4qzgDuYkkeDwOqAuyEWeK404vvdgv0A4Od1PMyWCawIw Download .mp4 (16.33 MB) Help with .mp4 files Supplementary Video 1eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxMDlmZWQwZDQ2YmU3M2EzNWQwZTE1MWVmOTIzODYwMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgxMjM3MjAyfQ.VlOIh7RMAdyyzik17pNvAp9gHD1go1tfVICZsIUR_IG3O_RDWKpvTEUeRbxR_p49LwkVlyG7HvbdgccwvN1n_D46lcvuOG1_0Vwf4ZAADJEC1So2VnxAJsnOPTgR37MkJ-8dB7M2gHhPEMD8tEU0QzZeFqEORX4oSXPF9zFVVPqQ-Op8WBRsKySy5WLvowQ_UrnT69KjBHd3-eg0owUpBm1_eLUFl6ksgWlCRZyb2sATPBl_UuiYSomNSTgl5lLA3q5QqUVonqqM9-0OQJrBsBhmCNmLAsuTze1aNDq0Xm5Z_L5Zj-tVFCDRPGWFsLRGlCRVC0b_lQrOJAbSpGLN5w Download .mp4 (4.3 MB) Help with .mp4 files Supplementary Video 2