Aneurysms of the gastric and gastroepiploic arteries are very rare, and most that
do occur are asymptomatic [1]
[2]
[3]. In some cases, however, they can be symptomatic, presenting with abdominal pain
or tender masses, or they can undergo erosion or rupture with massive bleeding [4]
[5]. We present the first case of arterial congestive gastropathy ever described.
A 34-year-old drug-addicted man with hepatitis C virus-related chronic hepatitis presented
at our emergency room having passed stools with a black appearance in the past 3 days.
He reported a previous history of endocarditis complicated by abscesses and mycotic
arterial embolisms that required mitral valve plasty, aortic valve replacement, several
embolizations, and laparotomic exclusion of a hepatic aneurysm. Abdominal examination
was unremarkable, and laboratory tests showed severe normocytic anemia (5.3 g/dL)
and an international normalized ratio (INR) below 7 due to uncontrolled chronic anticoagulation
with warfarin. Crystalloid fluids and 6 units of blood were infused. The overanticoagulation
required intravenous prothrombin complex concentrates combined with oral vitamin K.
Upper endoscopy revealed an appearance compatible with segmental portal hypertensive
gastropathy, with large gastric folds and mucosa characterized by a “snakeskin” appearance,
subepithelial hemorrhages, and increased vascularity along the lesser and greater
curvature of the stomach, fundus, and part of the body ([Fig. 1]), with diffuse fresh blood oozing. Epinephrine diluted 1 : 10 000 was injected,
but injection worsened active bleeding from a single point. Lauromacrogol 1.5 % 4 mL
was then used and this achieved bleeding control. No evidence of cirrhosis emerged
from the examinations.
Fig. 1 a, b Arterial hypertensive gastropathy aspect at upper endoscopy: a signs of diffuse neoangiogenesis and b snakeskin mosaic pattern with subepithelial hemorrhages, suggesting segmental hypertensive
gastropathy.
In view of the patient’s previous history and the endoscopic appearance, we decided
to perform computed tomography angiography, which showed an occlusion at the origin
of the splenic artery and common hepatic artery. Blood flow was provided by collaterals
originating from the gastroduodenal and left gastric arteries. The latter appeared
hypertrophic, with two aneurysms located along the smaller curvature and other hypertrophic
visceral vessels visible along the greater curvature and fundus ([Fig. 2]). To achieve reinforced bleeding control, arteriography was carried out ([Fig. 3]) with embolization of one aneurysm, followed by surgical gastric artery exclusion
to remove both aneurysms. Both procedures were successfully accomplished.
Fig. 2 Appearance of arterial hypertensive gastropathy at computed tomography angiography:
coronal section shows gastric wall thickening with hypertrophic arterial visceral
vessels along the fundus (arrows).
Fig. 3 Appearance of arterial hypertensive gastropathy at angiography: coronal section shows
gastric wall thickening with hypertrophic arterial visceral vessels along the fundus.
This case illustrates gastric arterial hypervascularization as an unusual cause of
arterial congestive gastropathy. In this situation, the endoscopic approach should
be avoided and angiography or surgery must be preferred.
Endoscopy_UCTN_Code_CCL_1AB_2AD
