# Clinical Cases: Stomach and Spleen ## Case 1: Bleeding Posterior Gastric Ulcer ### Clinical Presentation A 62-year-old male with a history of chronic NSAID use for osteoarthritis presents with melena for 3 days and an episode of hematemesis this morning. He reports epigastric pain that typically occurred 2-3 hours after meals and was partially relieved by antacids. Over the past week, the pain has worsened and now radiates to his back. He appears pale with blood pressure of 95/60 mmHg and heart rate of 115 beats per minute. After fluid resuscitation, upper endoscopy reveals a 2 cm ulcer on the posterior wall of the gastric body near the lesser curvature with a visible vessel at the base that is actively spurting blood. Epinephrine injection and hemoclip placement achieve initial hemostasis. However, the patient rebleeds 12 hours later with hemodynamic instability. Interventional radiology performs angiography demonstrating extravasation from the left gastric artery, which is successfully embolized. The patient stabilizes and is treated with high-dose proton pump inhibitors. ### Radiographic Findings ![Gastric Ulcer](case_01_image.jpg) *Image: Endoscopic view of a gastric ulcer showing mucosal defect with surrounding inflammation. Posterior ulcers may erode into adjacent vascular structures. Source: Wikimedia Commons, CC BY-SA 3.0.* ### Key Anatomical Points - The stomach receives its blood supply entirely from the celiac trunk through four main arteries along the curvatures - The left gastric artery (from celiac trunk) and right gastric artery (from hepatic artery proper) supply the lesser curvature - Posterior gastric ulcers on the lesser curvature may erode into the left gastric artery or splenic artery - The stomach bed includes the pancreas, which lies directly posterior to the stomach, separated only by the lesser sac ### Key Learning Points - Anterior ulcers tend to perforate into the peritoneal cavity; posterior ulcers tend to erode into vessels or the pancreas - Pain radiating to the back suggests posterior penetration into the pancreas - The rich anastomotic blood supply of the stomach makes it resistant to ischemia but explains the potential for significant hemorrhage - Gastric lymphatic drainage follows four zones that all ultimately drain to the celiac nodes --- ## Case 2: Splenic Rupture Following Blunt Trauma ### Clinical Presentation A 28-year-old female presents to the emergency department after a motor vehicle collision in which she was a restrained driver whose vehicle was struck on the left side. She complains of left upper quadrant and left shoulder pain. She is alert and oriented but appears anxious. On examination, blood pressure is 100/70 mmHg with heart rate of 110 beats per minute that increases to 125 on standing. The abdomen is tender in the left upper quadrant with guarding. FAST examination (Focused Assessment with Sonography in Trauma) reveals free fluid in the splenorenal recess and Morrison's pouch. CT scan with contrast demonstrates a grade III splenic laceration with active extravasation and moderate hemoperitoneum. Due to her hemodynamic instability despite resuscitation, she undergoes emergent splenectomy. She receives appropriate post-splenectomy vaccinations before discharge. ### Key Anatomical Points - The spleen lies in the left upper quadrant protected by ribs 9-11 in a posterolateral position - It is connected to the stomach by the gastrosplenic ligament (containing short gastric and left gastroepiploic vessels) - The splenorenal ligament connects the spleen to the left kidney and contains the splenic vessels and tail of the pancreas - Kehr sign (left shoulder pain) occurs from diaphragmatic irritation by blood - the phrenic nerve (C3-5) shares dermatomes with the shoulder ### Key Learning Points - The spleen follows the "1-3-5-7-9-11 rule": 1x3x5 inches, 7 ounces, ribs 9-11 - The splenic artery is an end artery with no anastomoses within the spleen - branch occlusion causes segmental infarction - Post-splenectomy patients require vaccination against encapsulated organisms (S. pneumoniae, H. influenzae, N. meningitidis) - The spleen normally holds 30% of the body's platelet pool --- ## Case 3: Gastric Outlet Obstruction ### Clinical Presentation A 48-year-old male with a long history of peptic ulcer disease presents with progressive nausea, vomiting, and early satiety over 2 weeks. He reports that his vomitus contains partially digested food eaten many hours earlier but no bile. He has lost 5 kg over the past month. On examination, he appears dehydrated with dry mucous membranes. A succession splash is elicited on abdominal examination. Laboratory studies reveal hypokalemic, hypochloremic metabolic alkalosis (pH 7.52, K+ 2.8 mEq/L, Cl- 88 mEq/L) from loss of gastric acid and potassium. Nasogastric tube insertion produces 1.5 liters of retained gastric contents. Upper endoscopy reveals severe scarring and stenosis of the pyloric channel from chronic peptic ulcer disease, preventing passage of the endoscope. After correction of electrolyte abnormalities and nutritional optimization, he undergoes laparoscopic pyloroplasty with relief of obstruction. ### Key Anatomical Points - The pylorus is the sphincter at the gastroduodenal junction, formed by a thick ring of circular smooth muscle - The pylorus lies at the level of the L1 vertebra at the transpyloric plane - Chronic inflammation and scarring can lead to pyloric stenosis and gastric outlet obstruction - The pylorus is innervated by vagal fibers that promote relaxation and sympathetic fibers that cause contraction ### Key Learning Points - Vomiting of non-bilious material indicates obstruction proximal to the ampulla of Vater (D2) - Succession splash is heard when the stomach is distended with retained fluid and air - Loss of gastric acid (HCl) causes hypochloremic metabolic alkalosis with paradoxical aciduria - The left gastric vein drains to the portal system and communicates with esophageal veins at the cardia