Necrotic Gastric Gangrene as Complication of Congestive Portal Venopathy from Portal Vein Thrombosis

A 58-year-old male with past medical history of chronic alcoholism, hepatitis C, and systolic heart failure with low ejection fraction presented to the emergency room with multiple episodes of hematemesis for 24 hours prior to the presentation. On arrival, he was hypotensive and tachycardic with impaired mentation. Laboratory findings revealed anemia (hemoglobin 9.4 gm/ dL), thrombocytopenia (platelets of 103,000/mm), acute renal failure, and lactic acidosis. The patient was appropriately resuscitated. An emergent esophagogastroduodenoscopy revealed normal esophagus with no esophageal or gastric varices but was noted to have generalized exudative necrosis and edematous mucosa in the body of the stomach and necrotic gastric mucosa in the antrum, appearance suggestive of severe gastric necrosis (Figures 1 and 2). During the procedure, patient developed cardiac arrest, and subsequently cardiopulmonary resuscitation was performed with return of spontaneous circulation after the first epinephrine injection. During the stay in intensive care unit, patient underwent vascular imaging studies, including CT angiogram of the abdomen and Doppler ultrasonography of the abdomen, which identified a large portal vein thrombosis with evidence of portal hypertension and signs of gastric necrosis. Patient was managed conservatively with nutritional support and antibiotics in intensive care unit. Subsequently he was discharged home with resolution of symptoms on follow-up appointment.