Diffuse Arterial Atherosclerosis Presenting With Acute Ischemic Gastritis

Ischemic gastritis is a rare cause of gastrointestinal bleeding due to the rich blood supply of the stomach. A 66-year-old lady with a history of coronary artery disease and hyperlipidemia presented with acute abdominal pain, diarrhea, and recent coffee-ground emesis. She had diffuse abdominal tenderness on physical exam with mild leukocytosis. A CT scan of the abdomen showed new peripheral wedge-shaped hypoenhancing regions in the spleen and both kidneys, suggestive of embolic infarcts. Posterior pneumatosis of the stomach suggestive of gastric wall ischemia was detected, with associated portal venous gas. She was started on heparin anticoagulation, broad-spectrum antibiotics, and intravenous fluids and underwent an urgent upper endoscopy showing hemorrhagic mucosa and fibrinous debris. A transesophageal echocardiogram showed mild aortic atherosclerosis. A CT angiogram of the abdomen showed calcified plaques at the origins of the hepatic artery, celiac artery, and superior mesenteric artery with severe ostial narrowing. Symptoms resolved, and she was started on statin therapy, prophylactic anticoagulation with apixaban, and high-dose peptic ulcer prophylaxis with pantoprazole. This ischemic gastritis case with multiple embolic spleen and kidney lesions is likely a sequela of extensive atherosclerosis and suggests that extensive atherosclerosis should be considered as a rare cause of acute gastrointestinal bleeding.