A0727 - Acute Gastric Ischemia Caused by Median Arcuate Ligament Compression Syndrome

Introduction: Gastric ischemia (GI) results from diffuse or localized vascular insufficiency and carries a poor prognosis. Although infrequently reported in the medical literature, it may be under-recognized clinically and histopathologically. We report a case of acute GI in a healthy 28-year-old woman due to underlying median arcuate ligament compression and precipitated by orthostatic hypotension that improved with supportive care.

Case Description/Methods: A 28-year-old woman with no past medical or substance use history presented to a community medical center with one day of severe, acute epigastric pain with associated nausea, emesis, and diarrhea. She had been experiencing episodes of orthostatic hypotension for the preceding several weeks. Vital signs and labs were normal. A nasogastric tube on suction revealed coffee-ground material. Abdominal CT showed mesenteric and portal venous gas, which prompted urgent transfer to a tertiary medical center. Upon arrival, an IV proton pump inhibitor was initiated, followed by esophagogastroduodenoscopy (EGD). A non-bleeding ulcer measuring 20mm x 30mm was found in the gastric fundus, and biopsies were taken. A subsequent CT angiogram showed a partial-thickness defect at the gastric fundus with no extraluminal gas to suggest perforation, median arcuate ligament compression of the celiac artery, and otherwise no vascular abnormalities. Pathology returned as oxyntic type gastric mucosa with acute hemorrhagic gastritis, consistent with acute ischemia. Subsequent management included nasogastric decompression, serial abdominal exams, and antibiotic therapy. Her pain gradually resolved with supportive care, and she was discharged four days later. A repeat EGD at 10 weeks showed grossly normal-appearing gastric mucosa, with histology of the gastric fundus showing mild, chronic gastritis.

Discussion: GI results from diffuse or localized vascular insufficiency caused by etiologies including arterial atherosclerosis, systemic hypotension, vasculitis, and disseminated thromboembolism. GI is infrequently reported in the medical literature, under-recognized clinically and histopathologically, and typically carries a poor prognosis. GI is a rare presentation of median arcuate ligament compression syndrome. Our case of GI is unique in that it occurred due to both localized and diffuse vascular insufficiency, with the combination of her underlying vascular structural abnormality and transient systemic hypoperfusion.