S4735 ACG—A Forgotten Hematemesis Syndrome

Introduction: Axon Clarke Gastropathy (ACG) is a rare gastrointestinal disorder involving gastric mucosal damage, commonly triggered by recurrent vomiting and retching. Symptoms like nausea, vomiting, and epigastric pain resemble cyclic vomiting syndrome (CVS) or functional dyspepsia (FD), complicating diagnosis. Severe cases may present with hematemesis or melena. Only 20%–30% of cases are correctly diagnosed, and many remain unidentified until significant gastric injury occurs highlighting the need for early recognition. First described by Axon and Clarke in 1975, ACG has been infrequently reported. It is often associated with psychiatric conditions (e.g., anxiety, depression) and chronic cannabis use. Hallmark endoscopic findings are erythema, hemorrhage, and mucosal prolapse help distinguish ACG from other GI disorders. Yet limited literature and lack of awareness delay diagnosis and treatment. This case series presents 2 patients with recurrent vomiting and gastric injury, underscoring diagnostic challenges. We aim to expand the differential, encourage timely recognition, and support multidisciplinary care. Case Description/Methods: Case 1: A 28-year-old man with attention-deficit hyperactivity disorder, anxiety, depression, hyperlipidemia, and daily cannabis use presented with 2 days of intractable nausea, vomiting, and dark emesis, preceded by epigastric burning and decreased appetite. Hemoglobin fell from 14 g/dL to 7.2 g/dL, indicating gastrointestinal bleeding. Computed tomography was unremarkable. Endoscopy showed hemorrhagic, erythematous, and prolapsing mucosa in the stomach body. Case 2: A 66-year-old man with gastroesophageal reflux disease (on lansoprazole), treated Hepatitis C, and daily cannabis use had 4 days of nausea, vomiting, and hematemesis with clots. On presentation, he was stable (Hgb 13.1, platelets 268, INR 1.4). Computed tomography revealed diffuse gastric inflammation. Endoscopy showed erythematous mucosa with submucosal hematoma and old heme in the gastric body. Biopsies confirmed hemorrhage in the lamina propria and reactive gastropathy. Discussion: Axon and Clarke initially described hematemesis and bright red gastric mucosa prolapsing into the esophagus. In our cases, damage was also concentrated in the proximal stomach, within 5 cm of the gastroesophageal junction, often along the lesser curvature. This differentiates ACG from Mallory-Weiss tears. Early recognition helps guide treatment to control vomiting and prevent mucosal injury. Although bleeding is often self-limited, prompt diagnosis improves outcomes.