Chronic Gastric Ischemia Leading to Gastric Perforation

Abstract

A 69-year-old man with diabetes, peripheral vascular disease, and hypertension presented with 3 months of diffuse abdominal pain that worsened with meals, weight loss, and dysphagia. Esophagogastroduodenoscopy and computed tomography revealed findings consistent with chronic gastric ischemia secondary to atherosclerosis. Gastric ischemia eventually led to perforation. We discuss causes, symptoms, diagnosis, and management of gastric ischemia, an underdiagnosed and potentially fatal condition that requires urgent diagnosis and treatment.

An Overview of Gastroduodenal Perforation

“…Perforated hiatus hernia or gastric volvulus, when part or all of the stomach is in the chest, present extremely difficult scenarios. Surgery in this situation may require thoracotomy, resection, and then a decision made regarding primary or delayed reconstruction (21,22). The influencing factors are the time since presentation, degree of mediastinal and pleural soiling, and the general condition of the patient (21,22,95).…”

“…Gastric volvulus and strangulated hiatus hernia ( 21 ) can lead to perforation if all or part of the stomach wall is rendered ischemic. Although the stomach has a good blood supply, on occasions severe foregut ischemia can lead to gastric ischemia and perforation, although such patients are generally unwell before the perforation is manifest ( 22 ). If perforation is in the thorax as in the case of strangulated hiatus hernia (HH), then the patient is likely to have chest symptoms and general signs of severe sepsis, with little or no evidence of peritonitis ( 21 ).…”

The surgical management of benign gastroduodenal perforation

“…Gastric volvulus and strangulated hiatus hernia [17] can lead to perforation if all or part of the stomach wall is rendered ischemic. Although the stomach has a good blood supply, on occasions severe foregut ischemia can lead to gastric ischemia and perforation, although such patients are generally unwell before the perforation is manifest [18]. The presentation of gastric perforation is sudden onset severe epigastric pain, peritonism, a board-like abdominal rigidity caused by spasm of the recti muscles and sepsis but may be non-specific in the elderly.…”

“…Perforated hiatus hernia or gastric volvulus, when part or all of the stomach is in the chest, present extremely difficult scenarios. Surgery in this situation may require thoracotomy, resection, and then a decision made regarding primary or delayed reconstruction [17,18]. The influencing factors are the time since presentation, degree of mediastinal and pleural soiling, and the general condition of the patient [17,18,82].…”

“…Surgery in this situation may require thoracotomy, resection, and then a decision made regarding primary or delayed reconstruction [17,18]. The influencing factors are the time since presentation, degree of mediastinal and pleural soiling, and the general condition of the patient [17,18,82]. It is important to remember that acute gastric dilatation is a common postoperative complication of major upper abdominal surgery although it is commonly seen in trauma, post splenectomy and with the gastric autonomic neuropathy of diabetes mellitus.…”