S2957 Chronic Mesenteric Ischemia: A Rarer Cause of Refractory Gastric Ulceration

Abstract

INTRODUCTION: H. pylori and non-steroidal anti-inflammatory drug (NSAID) use are common causes of peptic ulcer disease (PUD). In cases of refractory PUD after addressing these factors and treatment with a proton pump inhibitor (PPI), mesenteric ischemia should be considered. CASE DESCRIPTION/METHODS: A 74 year-old male experienced a non-ST segment myocardial infarction, underwent drug eluding coronary stenting, and was initiated on clopidogrel and aspirin therapy. That admission, he developed epigastric abdominal pain and “dark stools”. H. pylori serology was positive, and he was treated with high dose pantoprazole and amoxicillin. Despite twice daily PPI and NSAID avoidance, his epigastric pain persisted, so EGD was performed, revealing superficial, non-bleeding ulcerations and erythema in the gastric body; biopsies showed reactive gastropathy and congestion without H. pylori. 2 weeks later he developed overt melena, and small bowel enteroscopy revealed gastric mucosa pallor and an adherent clot overlying a 1 cm oozing peptic ulcer along the greater curvature. The ulcer was successfully treated with epinephrine and hemostatic clips. His pain symptoms and bleeding resolved, though a surveillance EGD 12 weeks later revealed persistent smaller ulcers, flat pigmented spots, and congestion adjacent to site of the larger ulcer. Sucralfate thus was added to his PPI regimen. He remained asymptomatic until his clopidogrel was discontinued, shortly thereafter developing severe epigastric pain. Physical exam was unremarkable and labs were notable for lactate 1.6 mmol/dL, hemoglobin 12.2 g/d, and gastrin 169 pg/ml (on PPI). CT angiogram showed 90% stenosis at the superior mesenteric artery (SMA) origin, high grade stenosis of the celiac and inferior mesenteric arteries, and dilated bowel. Endovascular intervention was attempted, but revascularization failed due to extent of disease, leading to open mesenteric bypass graft from the external iliac artery to proximal SMA. His dyspeptic symptoms completely resolved at 1 month follow up. DISCUSSION: Chronic ischemia rarely causes PUD due to highly-vascularized gastric mucosa. However, in cases such as this with severe stenosis of the major branches of the aorta this rare complication may occur. Mesenteric ischemia is an important diagnosis to consider in patients with refractory gastric ulcers, especially in the setting of known atherosclerotic disease. Mesenteric ischemia and its associated symptoms and mucosal injury can be successfully managed by revascularization.Figure 1.: EGD with superficial, non-bleeding ulcerations and erythema in the gastric body.Figure 2.: CT angiogram with stenosis of the superior mesenteric artery.Figure 3.: CT angiogram with stenosis of the superior mesenteric artery.