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I saw a news item today that said this:

The state medical examiner’s office ruled Tuesday that the death of a Trinity student in November was accidental and caused by a rare stomach disorder that was exacerbated by cocaine use.

Chief Medical Examiner James Gill said that Chase Hyde died of gastric ischemia that was complicated by recent cocaine use.

Okay, so the cocaine caused vascular constriction that exacerbated his undiagnosed preexisting condition and led to the ischemia. I get that, but that's not my question.

He was an apparently healthy young man experiencing protracted nausea and vomiting and he assumed it was due to food poisoning, which isn't an unreasonable assumption. Any physician would likely have assumed the same (or a viral infection) and treated it symptomatically, which would not have saved him.

My question is how might he have been successfully diagnosed and treated if he had sought treatment immediately? Is there any scenario in which an astute physician would have identified the actual cause and treated it given the emergent nature and short time frame available? If so, how?

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    @CountIblis Sure, but why would a doctor do endoscopy for an apparent food/viral illness in the first 24 hours? (And your link is just a login page) – Carey Gregory Apr 27 '19 at 4:03
  • It is hard to say whether his case could have been prevented since we don't have a full history. The ED definitely doesn't scope or scan every case that looks just like acute viral gastro/enteritis. It depends on what information is available at time of the differential diagnosis - if the patient gives a fully accurate and complete HPI and PMH etc, then excruciating abdominal pain or bloody vomiting/diarrhea in the setting of cocaine might raise a flag to consider vasospasm-induced enteric/gastric ischemia... are you looking for how the presentation of gastric ischemia differs from AGE etc? – DoctorWhom Apr 27 '19 at 5:03
  • @DoctorWhom are you looking for how the presentation of gastric ischemia differs from AGE etc? - Essentially, yes. – Carey Gregory Apr 27 '19 at 15:31
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    As Jan said, if a person is older, ischemia rises higher in a differential, but in a young person it is very rare. So this case would be extra challenging without a known history of ischemia or vasculopathy. A young man with epigastric pain and N/V would, in my estimation, raise suspicion for viral gastritis or gastric ulcer well above ischemic gastritis - except perhaps for the clue of cocaine as a vasoconstrictive agent, maybe. I'd be curious what Emergency Medicine colleagues would say about what red flags would prompt them to factor ischemic gastritis higher into a differential. – DoctorWhom Apr 30 '19 at 4:23
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Cocaine use is known to cause gastric ischemia or even perforation (in a 19 year old female student with epigastric pain PubMed, 2010) and in another 5 relatively young people (PubMed, 1991), or intestinal ischemia (PubMed, 1999). When there are no symptoms that would differ from those in food poisoning or infectious gastroenteritis, cocaine use alone should raise suspicion for gastric or intestinal ischemia.

Symptoms and signs associated with gastric ischemia can include nausea, vomiting, diarrhea, hypotension (as a cause of ischemia), abdominal pain (angina) and tenderness, chest pain (angina), vomiting blood and blood in stool (Journal Watch, 2014, PubMed, 2006).

It can also help to know the history of underlying conditions in gastric ischemia that can occur in young people: hypotension (e.g. due to arrhythmia or anaphylaxis), vasculitis, pyloric stenosis (which can lead to stomach distension) and paraesophageal hernia (Springer, 2017).

Diagnosis is by upper endoscopy (MedCrave, 2018).

In conclusion, symptoms and signs of gastric ischemia can be very unspecific, but you can suspect it in a person with sustained epigastric pain and known cocaine use.

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