Acute abdominal aortic occlusion due to gastric dilatation caused by pyloric stenosis in a 62-year-old patient

Abstract

Acute gastric dilatation leading to compromised vascular visceral vascular flow is an exceptionally rare complication typically described in patients with bulimia or anorexia following binge episodes. We present a fatal case involving a non-bulimic patient who experienced an acute gastric dilatation secondary to pyloric stenosis. Despite intensive treatment, the patient succumbed to complications arising from acute reperfusion syndrome. Managing such patients is highly challenging, and the prognosis is often poor, as supported by the limited reports available in the literature.

Case report

Gastric dilatation leading to the compression of the abdominal aorta is an extremely rare condition described in the literature primarily in patients with bulimia. However, a duodenal ulcer causing pyloric stenosis may also result in gastric dilatation that compresses the aorta and inferior vena cava, thereby compromising the perfusion of visceral organs and limbs. Despite immediate surgical intervention for gastric decompression, the outcome was fatal due to reperfusion syndrome.

A 62-year-old female was admitted to the emergency unit with severe sudden onset abdominal pain that had persisted for approximately 7 hours, initially, without any symptoms of lower extremity ischemia. Her past medical history was unremarkable, without any prior admission. She had no history of gastrointestinal disorders or vascular, neurological, or psychiatric diseases. On examination, she appeared critically unwell, with a distended abdomen and acute bilateral limb ischemia, stage IIB according to Rutherford classification scale, with sensory loss and paralysis. Femoral pulses were not palpable. Her blood pressure was 109/55 mmHg. Blood gas analysis revealed severe acidosis with a pH of 7.184, a lactate level of 13.3 nmol/l, hemoglobin at 12.5 g/dL, a hematocrit of 39.6%, alanine transaminase of 22 u/l, amylase of 18 U/l, bilirubin of 2.8 mg/dl, and creatinine of 1.6 mg/dl, with glomular filtration rate of 33 ml/min.

Ultrasound and abdominal computed tomography imaging demonstrated an extremely distended stomach compressing and obstructing the abdominal aorta and inferior vena cava, as well as the superior mesenteric artery, with radiological signs of bowel ischemia (Fig 1, Fig 2 and Fig 1, Fig 2). Several attempts of placing a nasogastric tube in the emergency room were unsuccessful, and patient was transferred immediately to the operating room. An urgent laparotomy revealed a gastric distention due to tight pyloric stenosis and visceral ischemia involving mainly small and large bowel. Gastric decompression was performed by gastrostomy, allowing insertion of a nasogastric tube and resulting in the immediate restoration of aortic flow and the reappearance of pulses in the femoral and superior mesenteric artery. The small intestine showed improved blood supply and viability, and clinical improvement of legs perfusion was noted. The patient was unstable and was transferred to the intensive care unit, and reassessment of the legs’ viability and second-look laparotomy was scheduled. Unfortunately, despite an intensive treatment including fluids, bicarbonates, vasopressors, and analgesics, the patient deteriorated rapidly, presenting multi-organ failure, systemic coagulopathy, acidosis with a drop of pH to 7037, and elevation of lactate to 28 nmol/l, and she died 7 hours post-admission.

Fig 1.

Compressed abdominal aorta by gastric distension.

Fig 2.

Tight pyloric stenosis causing gastric distension.

Discussion

Gastric dilatation is an extremely rare cause of aortic compression, leading to visceral and limb ischemia. Few reports have described this pathology, primarily in patients with bulimia and anorexia.^1,2 One fatal case involved a 3-year-old child with gastric distention compressing the aorta for an unspecified reason.³ Mechanical compression of the abdominal aorta by tension peritoneum has also been described in several reports.4, 5, 6

In the literature, we found only one case of a similar pathology involving compression of both the aorta and the inferior vena cava by a distended stomach.⁶ In our opinion, aortic occlusion in such cases may only occur in patients with healthy, non-atherosclerotic, compliant walls, concomitant with significant dehydration, and very high intra-abdominal pressure. It was described in the literature⁶ that an abdominal pressure exceeding 100 mm Hg can result in disappearance of femoral pulses. We observed that distended stomach may result in closing the gastroesophageal junction, making the insertion of a gastric tube in the emergency room challenging. An initial percutaneous drainage of the stomach may allow to restore the arterial flow and stabilize the patient preoperatively. However, in most cases, gastric decompression was followed by reperfusion syndrome, leading to multi-organ failure and coagulation disorders. We believe an immediate, aggressive treatment in such a condition is essential to save the patient’s life.

Disclosures

None.