29-Year-Old Man With Acute Gastric Distention

Question: A 29-year-old man presented to the emergency department with acute abdominal distention, nausea, and vomiting. The patient had undergone 2 laminectomies and spinal cord decompression surgery due to subdural and subarachnoid hematoma after rupture of an arteriovenous malformation 2 months ago and he experienced tetraparesis and dysfunction of the pelvic organs since surgery. He had been diagnosed with anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis and focal necrotizing and crescentic glomerulonephritis 10 years ago and for the last 5 years he was asymptomatic and did not undergo any treatment until the spinal cerebral incident. On arrival at the emergency department, he complained of abdominal pain, distention, and vomiting episodes. During the clinical examination, the patient's abdomen was distended and nontender. No rebound tenderness was evident. Normal white blood cell count with elevated C-reactive protein of 128.7 mg/L (normal <5 mg/L) was evident. Antibiotics were immediately started due to high inflammatory markers and suspected bacterial infection. Abdominal ultrasound was uninformative due to a large amount of intraluminal gas in the bowel, but there was suspected volvulus of the colon. Abdominal X-ray detected an extremely dilatated stomach without a clearly identifiable reason (Figure A). Portal venous gas shadow is evident in the liver, however, it was not reported on the original report. Nasogastric tube was inserted to remove the liquid from the stomach and an esophagogastroduodenoscopy (EGD) was performed. Dilatated stomach with a dark-colored mucosa of the posterior wall was visible (Figure B). Abdominal computed tomography (CT) with angiography was performed and revealed significantly dilated stomach (320 x 149 x 95 mm), pneumatosis of the gastric wall, air in the portal system, and significant stenosis (90%) of the proximal part of the celiac trunk (Figure C). What is the diagnosis? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Abdominal X-ray findings were informative (showed a highly dilatated stomach), but nonspecific. EGD suggested acute gastric ischemia due to the dark-colored mucosa of the posterior wall. Abdominal CT with angiography confirmed the diagnosis of gastric ischemia, pneumatosis of the gastric wall, and air in the portal venous system, but also revealed critical stenosis (90%) of the proximal part of the truncus coeliacus that was the reason for the gastric ischemia. Emergency angiography (Figure D) was performed with stenting of the truncus coeliacus (Figure E). After the procedure, antithrombotics were started and intravenous proton pump inhibitors were also administered. One week after stenting, repeated upper endoscopy showed superficial ulceration on the posterior wall of the stomach. After 12 months of follow-up, the patient had no stomach or abdominal symptoms and mucosal scar was visible on upper gastrointestinal endoscopy (Figure F). Acute gastric ischemia is an extremely rare clinical condition due to rich collateral blood supply of the stomach.1Tang S.J. Daram S.R. Wu R. Bhaijee F. Pathogenesis, diagnosis, and management of gastric ischemia.Clin Gastroenterol Hepatol. 2014; 12: 246-252.e1Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Although mesenteric ischemia accounts for only 0.09%–0.2% of all acute surgical admissions worldwide, acute truncus coeliacus ischemia is even more rarely reported in the literature.2Bala M. Kashuk J. Moore E.E. Kluger Y. Biffl W. Gomes C.A. et al.Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery.World J Emerg Surg. 2017; 12: 38Crossref PubMed Scopus (262) Google Scholar Predisposing factors, such as atherosclerosis, vasculitis, paraesophageal hernia, gastric volvulus, gastric dilation, disseminated intravascular coagulation, shock, and postoperative state, might increase the risk of gastric ischemia.3Carlos Silva J. Rodrigues A. Ponte A. Silva A.P. Carvalho J. A case of gastric ischemia: management and prognosis.GE Port J Gastroenterol. 2020; 27: 53-55Crossref PubMed Scopus (1) Google Scholar Unfortunately, our patient had a history of ANCA vasculitis that was most likely one of the causes of stenosis of the celiac trunk. The diagnosis of gastric ischemia should be considered for patients presenting with acute nonspecific symptoms: abdominal pain, distention, nausea, or vomiting. Although ultrasound is usually uninformative, for primary diagnosis, an abdominal x-ray may be chosen, where the dilated stomach is visible. EGD and endotracheal intubation to protect the airway during the EGD should be performed. Ischemic changes and their extent in the mucosa can be visualized on endoscopy. The most important diagnostic tool for gastric ischemia is CT angiography. It can identify the area of ischemic changes, possibly the cause (as in the presented case), and also the signs of perforation. If these are present, upper gastrointestinal endoscopy is contraindicated. The treatment of this disease includes immediate revascularization of the stomach, as in the presented case. Because the diagnosis and treatment were quick enough, full-thickness necrosis of the stomach was avoided. If the diagnosis is late and the stomach wall becomes necrotic, partial or total gastrectomy is required, depending on the extent of the necrosis. Gastric ischemia has a poor prognosis, so thorough clinical examination, early diagnosis, and prompt treatment are mandatory in preventing fatal complications.