Open Journal of Gastroenterology, 2013, 3, 314-316 OJGas
http://dx.doi.org/10.4236/ojgas.2013.37055 Published Online November 2013 (http://www.scirp.org/journal/ojgas/)
Idiopathic gastric partial necrosis*
Rocío González López#, M. Muinelo Lorenzo, J. Pérez Grobas, L. Muíños Ruano, L. Ramírez Ruíz,
A. Mohammed Salem, M. Rodríguez González, J. A. Costa Buján
Department of General Surgery and Digestive Diseases, Lucus Augusti University Hospital, Lugo, Spain
Received 21 August 2013; revised 28 September 2013; accepted 12 October 2013
Copyright © 2013 Rocío González López et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We present the case of an elderly patient, who had
orthopaedic surgery and suffered in the early post-
operative period an idiopathic gastric partial necrosis.
We reviewed the literature and it is an extraordinar-
ily infrequent entity. Partial resections have already
been described in case of limited necrosis, as reported
in our case. Prompt diagnosis of idiopathic gastric
necrosis and aggressive treatment are mandatory.
Further awareness of this strange entity and its risk
factors can lead to a quicker diagnosis and higher
possibilities of survival for the patient.
Keywords: Gastric; Necrosis; Orthopedic Surgery
Gastric partial necrosis is an extraordinarily infrequent
entity with very few cases described in literature. It has
been attributed to numerous aetiologies, such as lifestyle,
underlying morbidities, acute necrotising inflammation,
acute vascular insufficiency, post-operative complica-
tions, etc. .
The onset of symptoms is generally catastrophic and
surgical therapy must be urgent, as a delay in the diagno-
sis or treatment in these types of pathologies causes a
significant increase of morbimortality .
We describe the case of an elderly patient, who had
orthopaedic surgery and suffered in the early postopera-
tive period an idiopathic gastric partial necrosis. We re-
viewed the literature and it is the second case described
of idiopathic gastric partial necrosis attributable to or-
2. CASE REPORT
An 82-year-old man with a history of severe chronic ob-
structive pulmonary disease and hypertension under-
goes orthopedic surgery: total right hip replacement. 48
hours after the operation, he presents with distension and
abdominal pain, so urgent blood tests are carried out
showing acute renal failure, without leuko cytosis or neu-
trophilia. Given the suspicion o f intra-abdomin al free gas
in the simple abdominal X-rays, an urgent computed
axial tomography (CAT) is made, showing subcapsular
air and, in hepatic parenchyma predominant in left he-
patic lobe, portal gas and diffuse dilation of small bowel
loop together with gastric pneumatosis (Figure 1). The
patient is transferred to the Service of General Surgery,
where the yield of abundant amount of content in coffee
ground through nasogastric tube is noticed (NG tube), so
urgent upper gastrointestinal endoscopy (UGIE) is re-
quested, showing severe ischemia of the gastric wall in
the greater gastric curvature and gastric body. Given the
clinical worsening of the patient, urgent surgery is de-
cided, observing through midline laparotomy, ischemia
of greater gastric curvature up to the angle of His (Fig-
ure 2), the rest of the stomach showing good vasculari-
sation. Thus, it is decided to carry out an atypical gastric
resection, making a sleeve gastrectomy at the expense of
the lesser curvature.
The anatomopathological result showed transmural
ischemia. The post-operative complications included right
nosocomial pneumonia, with initial favourable develop-
ment. On the sixth post-operative day evisceration is
noticed, so urgent surgery is decided, observing anterior
gastric perforation at antral level, possibly related to the
NG tube position. No data of peritonitis, proceeding to
the primary closure of the perforation and to the closure
of the abdominal wall. The patient is sent to Resuscita-
tion, being operated four days later due to new gastric
perforation in the same antral area, making a new pri-
mary closure. After 24 hours, the patient passes away
due to multiple organ failure.
*Author contributions: González L. R. conceived of the study, drafted
the manuscript and performed the intervention. Muinelo L. M and
Pérez G. J. participated in the design of the study and performed the
intervention. Muíños R. L., Ramírez R. L., Mohammed S. A., Ro-
dríguez G. M., and Costa Buján J. A. performed the clinical research.
All authors read and approved the final manuscript.
R. G. López et al. / Open Journal of Gastroenterology 3 (2013) 314-316 315
Figure 1. Abdominal CT scan: showing subcapsular
air an d, in hepatic p arenchy ma predomina nt in left he-
patic lobe, portal gas and diffuse dilation of small bowe l
loop together with gastric pneumatosis.
Figure 2. Ischemia of greater gastric curvature up to the
angle of His.
Since the first case of acute gastric necrosis described in
1833 by Duplay, just a few cases of this infrequent pa-
thology have been published, maybe mainly because of
the rich gastric vascularization (right and left gastric ar-
tery, short gastric vessels and right and left gastroepip
loic arteries) [1,2].
Numerous aetiologies of this pathology have been dis-
cussed, but this is the second case attributable to the af-
termath of orthopedic surgery.
Gastric dilation might be very important, so as to pro-
voke abdominal compartment syndrome . When mas-
sive dilation occurs, ischemia is presumably due to ve-
nous insufficiency. Rupture can occur with intragastric
pressures of more than 120 mmHg (corresponding to
approximately 4 L of fluid. Distension and perforation
can rapidly lead to neurogenic (vagal response) and sub-
sequent septic shock. The repetitive massive consump-
tion of food in the case of food disorders and electrolyte
imbalances can lead to massive gastric distension. Me-
chanical factors can be implied in gastric dilation, like
bowel obstruction or pyloric stenosis, and infectious
causes (necrotising gastritis) have been reported, gener-
ally involving immunocompromised patients (diabetes,
AIDS, neoplasia). Physiopathologic theories have been
debated in the past: one advocated upper esophageal
sphincter relaxation (due to debilitation or anesthesia)
with consequent aerophagia and gastric dilatation as a
cause. Atonic theory (muscular atrophy during prolonged
starvation does not support rapid refeeding), superior
mesenteric artery syndrome (vascular co mpression of the
third duodenal portion) or functional diseases caused
from regional alterations (in pancreatitis, ulcer and other
abdominal inflammations) are other supposed etiologies
Clinically, emesis might be the initial symptom, but
events can precipitate suddenly to shock. Physical find-
ings are abdominal distension and tympanism, with ten-
derness and peritonitis in case of perforation. CT scan is
useful in the diagnosis as it can demonstrate gastric dis-
tension, portal gas, gastric pneumatosis and pneuroperi-
toneumm, as reported in our case. The UGIE can also
help for the pre-operatory diagnosis, but most times the
diagnosis is made during surgery [1,6].
Detension with nasogastric tube is mandatory as the
first therapeutical act, followed by immediate surgery in
case of perforation. Necrosis might be partial, mostly in
the lesser curve due to vascular supply). Total gastric-
tomy is the procedure of choice, but it requires time and
stable hemodynamic conditions. Mortality after gastric-
tomy in acute gastric necrosis is very high, ranging from
50% to 80% [1,6].
Partial resections have already been described in case
of limited necrosis, as reported in our case.
Unfortunately, a complicated post-operatory period
provoked the death of the patient despite the prompt di-
agnosis and surgery. In this patient, it is probably due to
multifactorial causes (previous short fasting, hyperten-
sive vascular disease, intubation, recent surgery, possible
undiagnosed thromboembolic accident), but none of
them stands alone as an evident reason for the catastro-
Prompt diagnosis of idiopathic gastric necrosis and
aggressive treatment are mandatory, but sometimes not
sufficient to save our patient, like in our case, especially
in older patients who can easily suffer irreversible multi-
ple organ failure.
Further awareness of this strange entity and its risk
factors can lead to a quicker diagnosis and higher possi-
bilities of survival for the patient.
 Vettoretto, N., Viotti, F., Taglietti, L. and Giovanelti, M.
(2010) Acute idiopathic gastric necrosis, perforation and
shock. Journal of Emergencies, Trauma and Shock, 3,
Copyright © 2013 SciRes. OPEN ACCESS
R. G. López et al. / Open Journal of Gastroenterology 3 (2013) 314-316
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