Gangrenous gastritis: Unusual cause of upper GI bleeding.

LEARNING OBJECTIVE #1: Mesenteric ischemia can present without abdominal pain especially if chronic due to formation of collateral vessels LEARNING OBJECTIVE #2: Weight loss in elderly can be the only sign of chronic mesenteric ischemia CASE: A 67 year old male with history of COPD and coronary artery disease presented with hematemesis and black stools for a day. He denied any abdominal pain, loss of appetite, or weight loss. No prior history of GI bleeding or postparandial abdominal pain. He was a current smoker with 50-year smoking history. On presentation he had BP of 146/94, pulse 83 and afebrile. Abdominal exam was unremarkable for tenderness. Bowel sounds were present. Rectal exam revealed black stools. Labs showed hemoglobin of 16. g/dl1, hematocrit 45%, WBC of 34,000 with 83% neutrophils, bicarbonate 20 mmol/L and INR of 1.7. EGD revealed inflamed gangrenous-appearing gastritis throughout with multiple clean ulcers, raising suspicion for ischemia. Cardia revealed extensive gastric ulcer; 5-6 cmin greatest dimension, with a large visible vessel. CTangiographyof abdomen showed proximal occlusion of Superior mesenteric artery (SMA), near complete occlusion of celiac artery and hypertrophic Inferior mesenteric artery which is likely the supply of much of his GI tract. Patient underwent successful SMA bypass from left iliac to mid. He was discharged home on aspirin daily. IMPACT: Clinicians should have a high index of suspicion in diagnosing intestinal ischemia in elderly patients with risk factors for atherosclerosis as clinical presentation can be misleading. Early diagnosis can prevent morbidity and mortality associated with this serious disease by decreasing the dreadful complication of bowel gangrene as developed in our patient. DISCUSSION: Patients with chronic mesenteric ischemia (CMI) typically present with recurrent abdominal pain after meals, resulting in fear of eating and weight loss. In a survey of 270 patients, weight loss, postprandial pain, adapted eating pattern, and diarrhea are associated with CMI. Probability of diagnosis increases to 60%with all four symptoms, and reduces to 13% if none are present. Few patients present with non-specific symptoms of nausea, vomiting and/or GI bleeding. This patient was unique in that he had no abdominal pain even with a total occlusion SMA, possibly due to well-formed collaterals which were seen in his CT abdomen. His upper GI bleeding as a result of gangrenous gastritis resulted from ischemic bowel from total occlusion. Review of literature shows delay in diagnosis ranges from 10.7 months to 15 months in diagnosing CMI, resulting in more complications. CT angiography abdomen is more than 90 sensitive and specific in diagnosing it. Endovascular therapy with stenting is the preferred method of revascularization in these patients and has widely replaced open surgical management. The non-specific symptoms and unremarkable physical exam in our patient demonstrate how silently intestinal ischemia can present