S6309 Recognizing Ischemic Gastropathy via Endoscopy

Introduction: Chronic mesenteric ischemia (CMI), defined as longstanding, inadequate gastrointestinal perfusion due to progressive narrowing of arteries of 70% or greater, is typically diagnosed and manifested clinically by postprandial abdominal pain, fear of eating, and weight loss. Risk factors for CMI are cardiometabolic in nature, however, exacerbation is enhanced by atherosclerosis, sedentary lifestyle, and extensive smoking. Furthermore, despite computed tomography (CT) angiography being the diagnostic modality of choice, gastric ischemia is infrequent due to its rich collateral blood supply and scarcely diagnosed via endoscopy, as highlighted in the following case. Case Description/Methods: A 72-year-old man with 54-pack-year smoking history presented with persistent abdominal pain and weight loss underwent an endoscopy which revealed gastric ischemic changes and ulcerations in the gastric antrum, with biopsies demonstrating reactive gastropathy and chronic inactive gastritis without H. pylori, dysplasia, or neoplasia. Afterward, he was started on proton pump inhibitor and sucralfate and had a CT angiogram showing near-total occlusion of the proximal celiac trunk and superior mesenteric artery. Subsequently, the affected vessels were stented by vascular surgery and the abdominal pain resolved within weeks. Discussion: Ischemic gastropathy due to CMI is typically a clinical diagnosis reached by assessing cardiometabolic and behavioral risk factors such as, atherosclerosis and smoking history, with the patient’s primary complaints of abdominal pain leading to weight loss due to fear of eating. Considering its extensive collateral blood supply, gastric ischemic injury is unusual, and symptoms of CMI can be masked and suspected by other etiologies. This particular case initially uncovered and recognized macroscopic ischemic changes via endoscopy and was confirmed by CT angiography. The expanding diagnostic modalities for ischemic gastropathy stem from the significant mortality rate within 6 months noted in prior studies. However, when a diagnosis is missed, delayed, or underrecognized due to nonspecific presentations, mortality rises exponentially. Detection via endoscopy, followed by imaging confirmation and subsequent endovascular intervention, ultimately led to symptom resolution, highlighting the importance of careful history-taking, thorough investigation, and detailed assessment, particularly in cases with nonspecific symptoms and associated risk factors.