Upper Gastrointestinal Bleeding after the Initiation of Enteral Feeding via a Gastrostomy Tube

An 84-year-old man was admitted to the author's hospital with dysphagia and prolonged disorder of consciousness due to late-stage Alzheimer's disease. Unfortunately, the symptoms had lasted for 1 month; thus, there was an indication of percutaneous endoscopic gastrostomy (PEG). Informed consent was obtained from the patient's family, and a PEG tube placement was performed without any complications. Enteral nutrition through the PEG tube was started on the third day after its placement. However, upon initiation of enteral feeding via the PEG tube, the patient suffered from massive diarrhea. Since vomiting occurred subsequently, enteral nutrition was discontinued. In addition, the PEG tube was opened for decompression, and antibiotics (ampicillin sodium/sulbactam sodium) were administered intravenously to prevent aspiration pneumonia. A few hours later, bloody fluid was observed through the PEG tube. Emergency esophagogastroduodenoscopy (EGD) revealed hemorrhage and severe erosions in the gastric cardia, fundus, and body (Fig. 1). Although the patient had taken a histamine-2 receptor antagonist (H2RA) (famotidine 40 mg twice-daily) for the prevention of peptic ulcer after admission, intravenous administration of a proton pump inhibitor (PPI) (lansoprazole 30 mg twice-daily) was prescribed as an alternative to H2RA. Follow-up EGD confirmed remarkable improvement of the gastritis (Fig. 2).

FIG. 1. Endoscopic view of hemorrhage and severe erosions in the gastric cardia (A, B), fundus (A), and body (B).

FIG. 2. Remarkable improvement of the gastritis (A: 4 days later, B: 18 days later).

The notable findings of the present case were as follows:

(1) Endoscopic view of the stomach showing segmental, well-defined red flares.

(2) Atypical location of the lesions.

(3) H2RA-resistant acute erosive gastritis.

The abovementioned findings were interpreted as suspicious of ischemic gastritis.

Ischemic gastritis occurs uncommonly because of the rich collateral blood supply of the stomach.1,2 Gastric ischemia is usually caused by systemic hypotension, vasculitis, or disseminated thromboembolism.2 In the present case, massive diarrhea could have contributed to the onset of ischemia. Common symptoms include abdominal pain, nausea, vomiting, and gastrointestinal bleeding.1 EGD is often used for diagnosis, and the characteristic endoscopic findings consist of a pale mottled mucosa, erythema, erosions, and confluent ulcerations.1,2 Depending on the etiology and severity, patients undergo supportive treatment (e.g., high-dose PPIs, intravenous fluids, antibiotics), revascularization, or surgery.1 Ischemic gastritis is related to a poor prognosis.1,2 In particular, the mortality is highest in patients with necrosis and perforation.1 Therefore, ischemic gastritis is a rare but important disease.