Indian Journal of Surgery August 2021 83 Suppl 3 :S785–S788

https://doi.org/10.1007/s12262-021-02922-y

CASE REPORT

A Rare Case of Acute Necrotizing Gastritis

Ravi Kumar Sabu Murugesan 1 & Suganth Annamalai 1 & Joyce Prabakar 1 & Kannan Ross 1

Received: 10 March 2021 / Accepted: 7 May 2021 / Published online: 17 May 2021
# Association of Surgeons of India 2021

Abstract
Stomach is a highly vascular organ in the gastrointestinal tract. It is very rare for a stomach to go in for gangrene even in cases of
volvulus. Spontaneous gangrene due to acute necrotizing gastritis is a very rare and dreaded condition. This condition is usually
not recognized preoperatively due to its rarity. Hence, early diagnosis and prompt expert management are necessary. Here, we
present a case of acute necrotizing gastritis which was admitted in our emergency department which was diagnosed to be a case of
gastric gangrene preoperatively with the help of radiological investigations.

Keywords Gastric gangrene . Stomach . Necrotizing gastritis . Shock

Introduction guarding. There was upper abdominal distension. There was

no audible bowel sounds. Per rectal examination revealed foul
Acute necrotizing gastritis is a variant of phlegmonous gastri- smelling blood tinged discharge. Patient was immediately re-
tis, with organisms producing necrosis and gangrene of the suscitated with crystalloids, antibiotics and analgesics.
stomach wall rather than just an intramural abscess [1]. In Nasogastric tube was inserted through which 2 L collection
acute necrotizing gastritis, all four major gastric vessels are of thick foul smelling, blood tinged fluid was drained.
patent, but gastric gangrene occurs secondary to an over- Complete blood count revealed leukocytosis. Patient was im-
whelming necrobiotic infection [2]. Here, we report a case mediately shifted for radiological investigations. Contrast en-
of 30-year-old gentleman without any previous complaints hanced computed tomography findings revealed grossly
and comorbidities presented with acute necrotizing gastritis. distended stomach with air fluid levels (Fig. 1). Prominent
intramural gas noted along the greater and lesser curvature
along with reduced enhancement of proximal portion of gas-
Case Report tric wall (Fig. 2). Multiple air pockets tracking to the portal
venous system are noted. One peculiar feature seen was re-
A 30-year-old gentleman presented with features of abdomi- duced aortomesentric angle (19 degree) which made a confu-
nal pain, fever, and vomiting for the past 2 days. He was on sion in the diagnosis.
intermittent long duration fasting for the past 15 days. Pain Free fluid noted in the abdomen and pelvis. Patient was
was severe in the epigastric region which was non-radiating proceeded with laparotomy. Intraoperative findings revealed
and was aggravated by food intake. He had normal bowel frank gangrene of the stomach involving the greater curvature
movements. On examination, patient was anxious, oriented, and fundus. The lesser curvature, gastroduodenal junction,
febrile with temperature of 101 °F. There was no pallor, icter- and the gastroesophageal junction were spared. There was
us. His vitals recorded a pulse rate of 120 per minute, blood no evidence of atherosclerosis, volvulus, or herniation.
pressure 90/60 mmHg, and normal oxygen saturation. His per Duodenum looked normal. Small bowel was dilated and mild-
abdomen findings revealed diffuse abdominal tenderness, ly edematous (Fig. 3).
more in the epigastric region which was associated with Total gastrectomy was performed, and duodenal stump
closed in two layers, planned for esophagojejunostomy (Fig.
4). In view of intraoperative hypotension, patient was started
* Ravi Kumar Sabu Murugesan
[email protected]
on dual inotrope supports. The distal esophageal end was fri-
able. In view of the above 2 factors, closure of distal esopha-
1
geal end with drain, feeding jejunostomy, and cervical
Institute of General Surgery, Madras Medical College, Chennai
esophagostomy was done.
Tamil Nadu India
S786 Indian J Surg August 2021 83 Suppl 3 :S785–S788

Fig. 1 Shows grossly distended

stomach with intramural gas

Fig. 2 Shows portal venous air

the right upper image
Indian J Surg August 2021 83 Suppl 3 :S785–S788 S787

uncommon compared with other parts of the gastrointestinal

tract [3]. Gastric gangrene could be secondary to atheroscle-
rosis, arterial embolism, iatrogenic gel foam embolism, ve-
nous thrombosis, gastric volvulus, bulimia nervosa, endo-
scopic hemostatic injections, diaphragmatic hernia, and infec-
tious gastritis [4]. The pathogenesis is unclear, although pre-
disposing factors include chronic gastritis, increased age, al-
coholism, hypoacidity, protein-energy malnutrition, and im-
munosuppression [5]. In acute gastric ischemia, patients can
develop nausea, vomiting, upper GI bleeding, abdominal dis-
tention, and symptoms and signs related to underlying predis-
posing conditions [6]. Phlegmonous gastritis can be diagnosed
by upper gastrointestinal endoscopy, CT scan, or endoscopic
ultrasound. Its endoscopic findings can show purple colored
Fig. 3 Intraoperative picture showing transition zone between the viable gastric mucosa covered with dirty necrotic materials. Absolute
antrum and the necrotic stomach diagnosis is made most frequently at laparotomy [7]. The
mortality associated with acute gastric necrosis ranges from
Patient could not be extubated on table due to severe he- 50 to 80% which underscores the severity or life-threatening
modynamic instability and severe metabolic acidosis and was nature of the condition. Significant mortalities have been re-
on ventilator support in the surgical intensive care unit. Inspite ported in recent publications even with aggressive manage-
of maximum dose of inotrope drug and acidosis correction, ment. The presence of circulatory collapse may be a signifi-
patient’s hemodynamic instability persisted, and he expired cant contribution to mortality [8]. The treatment of gastric
on the first postoperative day. ischemia includes fluid resuscitation, low intermittent naso-
gastric suction to combat gastric distension, intravenous pro-
Discussion The stomach is a well-vascularized organ that re- ton pump inhibitor therapy, and the select usage of broad-
ceives a blood supply from the left gastric artery (a branch of spectrum antibiotics if sepsis or gastric pneumatosis is present.
celiac axis), the right gastric artery (a branch of the common Angiographic interventions may be indicated in cases of
hepatic artery), the right gastroepiploic artery (a branch of the splanchnic vascular obstruction. Surgical intervention is indi-
gastroduodenal artery), the left gastroepiploic artery (a branch cated in cases of gastric perforation, gastric volvulus, or cases
of the splenic artery), and the short gastric arteries, which also of severe gastric ischemia, which fail to improve with medical
arise from the splenic artery. Therefore, gastric infarction is therapy [9]. Early resection of necrotic gastric wall combined
with adequate antimicrobial therapy is the cornerstone in treat-
ment of necrotizing gastritis [10].

Declarations

Ethical Approval Not required

Conflict of Interest The authors declare no competing interests.

References
1. Miller AI, Smith B, Rogers AI (1975) Phlegmonous gastritis.
Gastroenterology. 68(2):231–238
2. Strauss RJ, Friedman M, Platt N, Gassner W, Wise L (1978)
Gangrene of the stomach: a case of acute necrotizing gastritis.
Am J Surg 135(2):253–257. https://doi.org/10.1016/0002-
9610(78)90111-3
3. Zvizdic Z, Jonuzi A, Djuran A, Vranic S (2019) Gastric necrosis
and perforation following massive gastric dilatation in an adoles-
cent girl: a rare cause of acute abdomen. Front Surg 6:3. https://doi.
Fig. 4 Shows resected total gastrectomy specimen org/10.3389/fsurg.2019.00003
S788 Indian J Surg August 2021 83 Suppl 3 :S785–S788

4. Salroo N, Ahangar S (2012) Gastric gangrene “an iatrogenic mis- Konney TO, Adjei E, Boateng EA, Dally CK, Ababio KA, Afful-
adventure”. Indian J Surg 74(6):498–500. https://doi.org/10.1007/ Yorke D, Ahulu D (2020) Acute gastric necrosis in a teenager. Case
s12262-012-0509-5 Rep Surg 2020:Article ID 8882179, 4 pages. https://doi.org/10.
5. Perigela HC, Vasamsetty MK, Bangi VP, Nagabhushigari S (2014) 1155/2020/8882179
Gastric gangrene due to acute necrotizing gastritis. J NTR Univ 9. Sharma A, Mukewar S, Chari ST, Kee Song LMW (2017)
Health Sci [serial online] [cited 2021 Mar 6];3:38–40. Available Clinical features and outcomes of gastric ischemia. Dig Dis Sci
from: https://www.jdrntruhs.org/text.asp?2014/3/1/38/128429 62:3550–3556
6. Tang SJ, Daram SR, Wu R, Bhaijee F (2014) Pathogenesis, diag- 10. Kobus C, van den Broek JJ, Richir MC (2020) Acute gastric necro-
nosis, and management of gastric ischemia. Clin Gastroenterol sis caused by a β-hemolytic streptococcus infection: a case report
Hepatol 12(2):246–52.e1. https://doi.org/10.1016/j.cgh.2013.07. and review of the literature. Acta Chir Belg 120(1):53–56. https://
025 doi.org/10.1080/00015458.2018.1500799
7. Tejas AP, Rajagopalan S, Rohit K (2017) Necrotizing gastritis: a
case report. Int Surg J 4:3535–3538
Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
8. Yorke J, Gyamfi FE, Awoonor-Williams R, Osei-Akoto E,
tional claims in published maps and institutional affiliations.
Acheampong E, Acheampong EN, Adinku MO, Yamoah FA,