S6457 A Rare Presentation of Gastric Ischemia Manifesting as Gastric Pneumatosis in the Context of Amphetamine Use

Introduction: Gastric pneumatosis is a rare condition characterized by the presence of gas within the stomach wall. It may be associated with gastric ischemia, gastric intramural infection, mucosal disruption, increased intragastric pressure from gastric outlet obstruction, air dissection from the mediastinum, or barotrauma. Gastric ischemia is uncommon due to the stomach’s rich vascular supply but carries an increased risk of mortality. We present a rare case of gastric pneumatosis in the setting of gastric ischemia due to amphetamine use. Case Description/Methods: A 68-year-old man with amphetamine use disorder presented with abdominal pain, diarrhea, and hematemesis. Physical exam was unremarkable except for diffuse abdominal tenderness. Patient was found to have hypotension requiring fluid resuscitation and vasopressors. Urine drug screen was positive for amphetamine. Abdominal computed tomography (CT) showed a small amount of pneumatosis of the posterior wall of the stomach and adjacent mesenteric venous gas, concerning for ischemia and infarction. A nasogastric tube was placed for decompression, and the patient was started on ceftriaxone and metronidazole. Triple-phase abdominal CT showed chronic 50% luminal stenosis of the celiac and superior mesenteric artery origins. Due to the CT findings and hemodynamic instability, he underwent exploratory laparotomy and was found to have palpable gastric pneumatosis with no gross evidence of gastric ischemia, but intraoperative esophagogastroscopy showed patchy ischemic changes of the posterior stomach wall and gastroesophageal junction. He was managed conservatively, achieved hemodynamic stability postoperatively, and reported symptomatic improvement. Discussion: Amphetamine use can lead to significant nonocclusive mesenteric ischemia through microvascular damage and vasospasm, which can result in mucosal injury and necrosis. While amphetamine-associated mesenteric ischemia is well documented, its link to gastric pneumatosis/ischemia is rarely reported. His chronic celiac artery disease predisposed him to gastric ischemia, which was triggered by amphetamine use. Our case highlights the need to consider gastric ischemia in patients with amphetamine use disorder presenting with nonspecific gastrointestinal symptoms and imaging suggestive of gastric pneumatosis. Early recognition of gastric pneumatosis is crucial to improve patient outcomes, as it may indicate ischemia and carries a risk of increased mortality.