Severe Erosive Ischemic Gastritis Healed After Surgical Revascularization
Article Outline
Abstract
Gastritis secondary to splanchnic arterial insufficiency is rare. The diagnosis should be suspected in case of gastritis associated with occlusion of celiac axis and superior mesenteric artery. We report a patient with severe ischemic gastritis who completely healed after surgical reno-hepatic bypass. This retrograde revascularization avoids aortic clamping and was well tolerated. Ischemic gastritis belongs to the celiac-territory ischemic syndrome and cholecystectomy should be added to the revascularization to prevent post-operative acute ischemic cholecystitis.
Keywords: Mesenteric ischemia, Intestinal ischemia treatment, Surgical revascularization, Acute gastritis, Acute cholecystitis
Introduction
Ischemic gastritis (IG) caused by splanchnic arterial insufficiency is rare because of the rich collateral blood supply of the stomach, and is only seen when at least two of the three main splanchnic arteries are occluded or severely stenosed. We present a case of a completely healed IG after celiac revascularization.
Case Report
A 59-year-old male was hospitalized complaining of sudden onset of upper abdominal pain associated with haematemesis. He was known to have hypercholesterolemia, severe hypertension, and atherosclerotic occlusive disease of lower extremities. He smoked 40 cigarettes daily for 30 years (60 pack/years). One year ago, he underwent Hartmann's procedure for a perforated sigmoid diverticulitis followed by subtotal colectomy with small bowel resection few months later for acute intestinal ischemia. He was on parenteral nutrition. His abdomen was hostile, due to his previous operations.
Laboratory tests revealed renal failure with no post-renal obstruction found on renal ultrasound.
Gastroduodenoscopy revealed mucosal IG with local necrosis in the gastric fundus (Fig. 1).
Figure 1
Necrosis of the fundus gastric mucosa during gastroduodenoscopy.
Abdominal CT scan revealed a atheromatous stenosis of the ostium of the common celiomesenteric trunk. Distal part of the superior mesenteric artery (SMA) was patent. Right and left renal arteries were free of atherosclerosis (Fig. 2).
Figure 2
Abdominal CT scan showing stenosis of a common celiomesenteric trunk (A), patency of distal part of the superior mesenteric artery (B) and a severely calcified infrarenal aorta (C and D).
The cardiovascular evaluation revealed a normal left ventricular ejection fraction at 60% with no other anomalies.
As no endovascular therapy was deemed possible, the decision was made to perform surgical revascularization. Operative findings showed well vascularized gastric serosa, but weak pulsation was detected in the hepatic pedicle. To avoid celiac aorta clamping, a retrograde bypass revascularization between the right renal artery and the common hepatic artery was performed using a saphenous vein graft. Cholecystectomy was performed as well.
The patient's postoperative recovery was uneventful. No renal failure was noticed. A gastroduodenoscopy performed postoperatively at day 7 showed healed gastric mucosa (Fig. 3). Reno-hepatic bypass was permeable on abdominal CT scan at day 10 postoperatively. The patient remained asymptomatic on follow-up at one month.
Figure 3
Gastroendoscopy showing gastric mucosa healed after surgical revascularization of celiac artery.
Discussion
IG is an unusual presentation of splanchnic vascular insufficiency. Nearly 50% of patients with IG were previously treated for an ulcerative pathology or duodenitis before splanchnic vascular insufficiency was diagnosed. The mechanism for such lesions entails diminished mucosal resistance as a result of reduced blood flow.1 The diagnosis should be suspected in case of atherosclerotic occlusive disease of lower extremities, previous surgery for acute or chronic intestinal ischemia, and in heavy smokers. The gastric blood supply arises mainly from the celiac artery (CA), the SMA via the pancreaticoduodenal collaterals and the right gastro-epiploïc artery, the oesophageal arteries, and the left inferior phrenic artery. Because of the rich collateral blood supply, IG only occurs when both CA and SMA are occluded. It is well recognised that acalculous cholecystitis (Ac) can complicate aortic surgery. Therefore, we performed cholecystectomy for the following reasons: Firstly, acalculous cholecystitis belongs to the celiac-territory ischemic syndrome; secondly, the diagnosis of post-operative Ac is difficult and finally, the associated-morbidity of cholecystectomy is minimal compared to the prognosis of post-operative Ac.
The SMA is the predominant artery in chronic intestinal ischemia and its revascularization should be considered first.2, 3 In case of isolated supramesocolic vascular insufficiency (gastro-duodenal ulcer, Ac, hepatic or splenic ischemia), CA revascularization should be considered as a priority. Retrograde bypass like reno-hepatic revascularization, avoid clamping the celiac aorta and lower the mortality rate in patients with coronary artery disease. In our case, retrograde bypass from was considered dangerous because of a severely calcified infrarenal aorta making aortic clamping difficult. One report underlines the success of endovascular SMA stenting for IG.4 Percutaneous angioplasty should be preferred in older patients because of its lower mortality and morbidity rate compared with open revascularization.5 However, the main disadvantage would be the inability to perform cholecystectomy.
In conclusion, ischemic gastritis belongs to the celiac-territory ischemic syndrome like Ac. Emergent celiac revascularization is paramount for gastric healing. Retrograde reno-hepatic bypasses are an efficient alternative to the antegrade bypasses requiring aortic clamping. Cholecystectomy prevents post-operative acute ischemic cholecystitis.
Conflict of Interest
None.
Funding
None.
References
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PII: S1533-3167(09)00021-1
doi:10.1016/j.ejvsextra.2009.05.001
© 2009 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Severe Erosive Ischemic Gastritis Healed After Surgical Revascularization , 02 July 2009
