A case of gastric fundal perforation secondary to thrombotic occlusion of celiac artery

A 50-year-old male presented to the emergency department with acute abdominal pain and vomiting. Upon admission he was tachypnoeic. He had tachycardia and his blood pressure was stable. Physical examination revealed tense and tender abdomen.

Plain radiograph chest and abdomen erect showed free air under diaphragm. Patient then underwent emergency contrast CT abdomen with intravenous contrast. Pre-contrast CT abdomen showed extensive pneumoperitoneum in the abdomen (figure 1 ) and fluid collection posterior to gastric fundus ( figure 2). Contrast-enhanced CT shows hypodense filling defect in celiac axis (Figure 3a, 3b) causing luminal narrowing and wedge-shaped non-enhancing areas in spleen, suggestive of splenic infarct ( figure 4). With high suspicion of possible perforation of stomach, oral positive contrast was administered to demonstrate the site of leak. CT abdomen with positive oral contrast showed a small perforation in fundus of stomach(figure 6) and leak of contrast into peritoneal cavity (figure 5).

Patient was taken up for laparotomy. The perforation site (figure 7) was closed with sutures and sealed with omental patch.

Background

Perforation of gastrointestinal tract is a life threatening surgical emergency, associated with significant mortality rates[1]. As per literature, the most common site of perforation was seen in the gastroduodenal region [2]. The most common aetiology for gastric perforation is peptic ulcer disease, followed by trauma, malignancy, interventional procedures[3] Gastric ischemia is uncommon with  Ischemic necrosis occurs more frequently in organs supplied by end arteries.

Clinical Perspective

Clinical presentation depends on the site of perforation. In perforation there is a breach in the wall of the viscus, leading to direct communication of the gastric contents to the peritoneal cavity, leading to chemical peritonitis in the acute setting [1]. Presentation is nonspecific, consisting of abrupt onset persistent abdominal pain unresponsive to medication which evolves into sepsis and peritonitis if left untreated[1]. Hence timely diagnosis and intervention are needed to decrease morbidity and mortality.

Imaging Perspective

Plain radiograph of abdomen gives initial clue in the form of pneumoperitoneum with a sensitivity of about 50-70%. Multidetector Computed Tomography (MDCT) is however more sensitive in detecting the pneumoperitoneum and determining possible site of perforation. Overall accuracy of CT abdomen in predicting the site of perforation approaches 86%. The imaging features which assist in determining the site of perforation are concentration of extraluminal air, segmental bowel wall thickening or direct visualisation of defect in the wall. CT can also determine cause of perforation.[4]

Acute celiac artery obstruction can result from atherosclerosis, aneurysm, dissection, embolisation of intracardiac thrombi in atrial fibrillation, coagulation disorders caused by HIV infection, external arterial compression by the median arcuate ligament [5]. The underlying cause of thrombosis, in this case, is likely due to atherosclerosis, considering the age of the patient and underlying risk factors of diabetes and hypertension and presence of calcified wall thickening of aorta and iliac vessels.

The perforation in our case occurred in the gastric fundus, an area supplied mainly by the left gastroepiploic and short gastric arteries. MDCT (multidetector Computed Tomography) revealed extensive thrombus in the celiac artery in arterial phase.

Outcome

Initial management consists of aggressive resuscitation, oxygen therapy, intravenous fluids, and broad-spectrum antibiotics. A nasogastric tube should also be placed.

Definitive surgical treatment should be done at the earliest possible time which includes closure of defect by suturing alone or along with omental patch repair[3].

Take-Home Message/Teaching Points

Gastric perforation is an acute surgical emergency. Imaging plays a role in timely diagnosis of the condition and in determining the site and possible underlying aetiology. Contrast-enhanced CT is the imaging modality of choice in the workup of this surgical emergency.