Winner of ACP National Poster Competition

Dr. Beheshteh Nakhaee

Title: First Case Report of Methamphetamine-Induced Gastric Pneumatosis in a 46 YO Without Known Vascular Disease.

Introduction:
Gastric pneumatosis, or air within the wall of the stomach, is considered a life-threatening emergency because it usually reflects severe mesenteric necrosis, although there can be relatively benign etiologies. In 90% of cases markers such as lactic acid are often high. Here, we present a relatively young diabetic man without any established vascular disease or gastric pathology. This case is atypical in that he experienced a prolonged symptomatic period, his lactic acid was normal, but surgical findings revealed extensive gastric necrosis; he recovered uneventfully following subtotal gastric resection.

Case:
The patient was a 46-year old Hispanic male with 5 days of epigastric pain; he had not sought medical help earlier because he was involved in family member’s funeral. He reported nausea, bloating, black stools without vomiting, fever and chills. He had no prior gastric symptom or treatment. He was a smoker but had no recent drug or alcohol use. He had no history of vascular disease, and had been treated for hypertension and diabetes type 2 for only 4 years. He was on aspirin intermittently but had taken none in the 6 days prior to presentation. On physical examination, his abdomen was soft, with moderate tenderness over the epigastrium without rebound or rigidity. The rest of examination was unremarkable. Laboratory revealed potassium of 6.8, but lactic acid level was normal, and there was otherwise no evidence for ketoacidosis or hyperosmolarity. The initial diagnose was upper gastrointestinal bleed. Because of the hyperkalemia and tenderness, a CT was ordered, which revealed air in the posterior wall of stomach and portal vein. Upper endoscopy revealed extensive black necrosis of the anterior and posterior walls of the stomach. Surgery was performed immediately with near total resection of the stomach. The patient tolerated the surgery well and was later discharged in good condition. Pathology showed ischemic necrosis without evidence of infection, vasculitis or any arterial occlusion. Later review of the pre-hospital outpatient chart patient showed a positive urine methamphetamine urine screen (the day before the start of abdominal pain).

Discussion:
Gastric pneumatosis is rare and can be due to ischemia, infection or damage to the mucosal barrier from local pathology. Those with true ischemia usually have history of CAD, peripheral vascular disease, renal replacement therapy and atrial fibrillation. Gangrenous gastric pneumatosis generally carries a grave prognosis and is associated with lactic acidosis, and in diabetics, DKA or hyperosmolar state. Our patient was remarkable for his relatively young age, subacute presentation, with no known or evident vascular disease, no diabetic complications and no lactic acidosis despite hyperkalemia. The most likely etiology of GASTRIC PNEUMATOSIS in our patient was METHAMPHETAMINE-induce gastric ischemia in a patient pre-disposed by long-standing DM, HTN, and smoking. While cocaine and methamphetamine use have been reported as causes of ischemic colitis and mesenteric ischemia, there have been no prior case reports of ischemic gastric necrosis or pneumatosis. Given the high prevalence of cocaine and methamphetamine abuse, it is essential for clinicians to be aware of even infrequent complications. In a young patient with suspected stimulant abuse, abdominal pain from ischemic necrosis should be considered.

Category: Clinical Vignette
First Author: Associate
Name: Beheshteh Nakhaee
Additional Author: Philip H. Goodman, MD, MS, FACP

Page updated: 6/29/2009

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