Abstract
Ischemic gastropathy is a rare, underreported phenomenon that is associated with a poor prognosis. Patients often present with signs of shock, gastrointestinal bleeding, and anemia. We describe a patient with alcoholic cirrhosis who presented after a fall in hemorrhagic shock. Initial endoscopy revealed evidence of ongoing bleeding, with subsequent endoscopy revealing the “leopard skin” appearance in the stomach. The patient was treated supportively but eventually succumbed to his condition. Prompt diagnosis, treatment, and awareness of the delayed changes on upper endoscopy are imperative in diagnosing ischemic gastropathy. Patients with risk factors for the condition need to be given additional consideration for this diagnosis.
Keywords: Ischemic gastropathy, leopard skin stomach
Gastric ischemia is uncommon because of rich collateral vascular supply to the stomach.1 Predisposing conditions include hypotension, vasculitis, mechanical obstruction, and endoscopic complications.2–4 It is often underreported and fatal, making it essential to recognize and report this condition.2 We present a case of ischemic gastropathy with “leopard skin” stomach in a cirrhotic patient who presented after a fall with melena and hemorrhagic shock.
CASE REPORT
A 62-year-old man with a past medical history of alcoholic cirrhosis presented to the emergency department 8 hours after an unwitnessed fall while intoxicated. His blood pressure was 89/52 mm Hg, heart rate 109 beats/min, temperature 92.2°F, respiratory rate 22 breaths/min, and oxygen saturation 96% on room air. The patient had multiple episodes of melena. He was awake but lethargic, with scleral icterus. Table 1 shows the laboratory findings. Computed tomography (CT) of the chest, abdomen, and pelvis without contrast was consistent with cirrhosis, mild to moderate ascites, and pancolitis. The patient was admitted to the surgical intensive care unit for hemorrhagic shock and started on a massive transfusion protocol.
Table 1.
Laboratory test results at presentation
| Laboratory test | Result |
|---|---|
| White blood cells (× 109/L) | 13.5 |
| Hemoglobin (g/dL) | 6.3 |
| Platelets (× 109/L) | 99 |
| Creatinine (mg/dL) | 1.44 |
| Blood urea nitrogen (mg/dL) | 7 |
| Potassium (mmol/L) | 2.9 |
| Bicarbonate (mmol/L) | <7 |
| Lactic acid (mmol/L) | >20 |
| Aspartate aminotransferase (U/L) | 157 |
| Alanine aminotransferase (U/L) | 42 |
| Creatine kinase (iU/L) | 471 |
| Total bilirubin (mg/dL) | 5.5 |
| Albumin (g/dL) | 1.4 |
| Ammonia (umol/L) | 168 |
| International normalized ratio | 2.20 |
| pH, arterial blood gas | 6.99 |
| Carbon dioxide (mm Hg) | 14.6 |
Esophagogastroduodenoscopy (EGD) showed two mucosal defects in the esophagus suspicious for perforation vs diverticulum at 34 cm from the incisors with air bubbles seen from one of the defects. Diffuse severe mucosal changes were characterized by discoloration and hemorrhagic appearance in the mid and distal esophagus. Hematin was found in the entire examined stomach with no clear visualization. EGD was aborted due to concern for esophageal perforation. CT of the chest, abdomen, and pelvis with contrast showed no esophageal leak. The patient was treated with broad-spectrum antibiotics, vasopressors, octreotide, pantoprazole drip, and prokinetic agents for better visualization. Repeat endoscopy performed due to continued melena showed multiple linear esophageal ulcers concerning for necrotic/ischemic esophagus and grade 1 varices in the lower third of the esophagus. Many gastric punctate ulcers oozing fresh blood were found along the greater curvature of the stomach. The finding of punctate gastric ulcer, referred to as “leopard stomach” (Figure 1), is a characteristic secondary to severe ischemic gastropathy. He was deemed a poor surgical candidate due to worsening coagulopathy with multiorgan failure and was eventually transitioned to hospice care.
Figure 1.
Gastric body ulcers.
DISCUSSION
Ischemic gastropathy is rarely reported and likely underrecognized, though it generally has a poor prognosis.1–3 Gastric ischemia is highly uncommon due to redundancy, anastomoses, and extensive collaterals of the vascular supply.1,5 The clinical presentation of gastric ischemia depends on the acuity and extent of ischemia development, with acute cases warranting immediate intervention.1,3 Symptoms vary but include nausea, vomiting, abdominal distension, weight loss, and gastrointestinal bleeding,3,6 similar to our patient. Gastric ischemia arises due to various underlying conditions such as hypotension, vasculitis, mechanical obstruction, or ischemia related to complications of endoscopic interventions.2–4 However, there have been only a few reports of gastric ischemia in patients with cirrhosis.1,7 In our cirrhotic patient, portal hypertension could have been a predisposing factor for ischemic gastropathy. The alteration in gastric mucosal hemodynamics with passive congestion in individuals with portal hypertension results in poor gastric perfusion, making patients susceptible to gastric ischemia.8 In addition, gastric distention contributes significantly to the development and worsening of ischemia, warranting immediate nasogastric tube placement.1
Imaging including CT scan can suggest ischemic changes, such as gastric wall pneumatosis. However, a negative CT scan does not rule out the potential for gastric ischemia; endoscopy is a more sensitive modality.2 Congestion, hemorrhagic mucosa with or without ulceration, or frank necrosis are typical EGD findings.1,2 Ischemic ulcers are typically located around the anastomoses that connect the two arterial arches from the lesser to greater curvature, running along the anterior and posterior stomach walls.1 In addition, the characteristic finding of “leopard skin,” as seen in our patient, indicates areas of subepithelial hemorrhage.9
Treatment includes conservative therapy with pantoprazole, antibiotics, nasogastric tube decompression, and surgical techniques such as stent implantation for revascularization and gastrectomy.2 However, treatment depends on the cause and extent of the ischemic damage.1,3 A retrospective review of 17 patients presenting over 16 years showed a 6-month mortality rate related to gastric ischemia of 24%.2 Another case series of 12 patients found a 30-day mortality rate of 33% and a 1-year mortality rate of 41%.3 Overall, the condition has a poor prognosis.1–3 Our patient, who unfortunately suffered multiorgan failure, was eventually transitioned to comfort care. The case highlights the “leopard skin” appearance in the stomach in patients with ischemic gastropathy.
Disclosure statement/Funding
The authors report no funding or conflicts of interest. Permission was obtained from the patient to publish this case report.
References
- 1.Tang SJ, Daram SR, Wu R, Bhaijee F.. Pathogenesis, diagnosis, and management of gastric ischemia. Clin Gastroenterol Hepatol. 2014;12(2):246–252.e1. doi: 10.1016/j.cgh.2013.07.025. [DOI] [PubMed] [Google Scholar]
- 2.Sharma A, Mukewar S, Chari ST, Wong Kee Song LM.. Clinical features and outcomes of gastric ischemia. Dig Dis Sci. 2017;62(12):3550–3556. doi: 10.1007/s10620-017-4807-4. [DOI] [PubMed] [Google Scholar]
- 3.Elwir S, Shaukat A, Mesa H, Colbach C, Dambowy P, Shaw M.. Ischemic gastritis: a multicenter case series of a rare clinical entity and a review of the literature. J Clin Gastroenterol. 2016;50(9):722–726. doi: 10.1097/MCG.0000000000000468. [DOI] [PubMed] [Google Scholar]
- 4.Albuquerque A, Ramalho R, Rios E, Macedo G.. Ischemic gastropathy. J Gastrointestin Liver Dis. 2012;21(1):8. [PubMed] [Google Scholar]
- 5.Chaudhry SR, Liman MNP, Peterson DC.. Anatomy, abdomen and pelvis, stomach. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2022. [PubMed] [Google Scholar]
- 6.Casey KM, Quigley TM, Kozarek RA, Raker EJ.. Lethal nature of ischemic gastropathy. Am J Surg. 1993;165(5):646–649. doi: 10.1016/S0002-9610(05)80453-2. [DOI] [PubMed] [Google Scholar]
- 7.Kim SY, Han SH, Kim KH, et al. Gastric ischemia after epinephrine injection in a patient with liver cirrhosis. World J Gastroenterol. 2013;19(3):411–414. doi: 10.3748/wjg.v19.i3.411. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Iwao T, Toyonaga A, Ikegami M, et al. Reduced gastric mucosal blood flow in patients with portal‐hypertensive gastropathy. Hepatology. 1993;18(1):36–40. doi: 10.1002/hep.1840180107. [DOI] [PubMed] [Google Scholar]
- 9.Lee TC, Lin JT, Liang CW, Wang HP.. Ischemic gastropathy: leopard skin in the stomach. Endoscopy. 2005;37(9):927. doi: 10.1055/s-2005-870437. [DOI] [PubMed] [Google Scholar]