Fatal Gastric Ischemia in a 12-Year-Old After Accidental Substance Exposure

A previously healthy twelve-year-old girl died of gastric ischemia and necrosis after an undisclosed toxicological exposure, according to a case report published in the Egyptian Pediatric Association Gazette. The report, authored by Omar M. Ahmed, Sayed Khedr, Manal Mahmoud and Basma Magdy, describes how the child arrived at an emergency department in total systemic collapse, with an altered level of consciousness and status epilepticus following twelve hours of vomiting and severe abdominal pain. Toxicology screening later returned positive for both cannabis and benzodiazepines, although her guardians denied any access to drugs or substances. The clinical course, which included emergency surgery and a partial gastrectomy, ended in fatal multiorgan dysfunction on postoperative day seven.

The presentation was dramatic from the moment of arrival. Initial blood gases showed severe combined metabolic and respiratory acidosis, with a pH of 7.14, a pCO2 of 51.4 and a bicarbonate of 17.2. Her condition deteriorated to the point that she required cardiac inotropic support and invasive ventilation after three cycles of cardiopulmonary resuscitation. The authors emphasize that the child had been previously healthy, with no chronic conditions that would have predisposed her to vascular compromise of the stomach.

Abdominal examination revealed generalized rigidity suggestive of peritonitis, and a gastric tube retrieved brownish necrotic aspirate, a finding that pointed toward dead or dying stomach tissue. Bedside ultrasonography documented a mild pelvic collection, and a plain abdominal X-ray showed absent aeration. Laboratory results added to the picture of a critically ill child: a hemoglobin of 14.5 g/dl, a platelet count of 264 x 10^3/mm3, and leucopenia with a leucocytic count of 2.8 x 10^3/mm3, along with an impaired coagulation profile consisting of a prothrombin time of 16.8 seconds and an International Normalized Ratio of 2. Serum chemistry showed mild renal impairment, with a creatinine of 1.15 mg/dL and a urea of 61 mg/dL, as well as hypokalemia at 3 mEq/L, while sodium remained normal at 141 mEq/L.

The social circumstances surrounding the case proved to be an important part of the story. While the guardians initially denied any access to drugs, further history-taking revealed parental separation that had been concealed, and the child resided primarily with her grandparents. The toxicology screen identifying cannabis and benzodiazepines was the only direct laboratory evidence of what the child had been exposed to, and the report does not identify a specific agent as the confirmed cause of the gastric injury.

After twenty-four hours of active resuscitation, the surgical team took the child to the operating room. Laparotomy revealed healthy bowel loops, a mild collection, omental calcification and an ischemic stomach. The ischemia involved the fundus and the greater curvature of the stomach, and a partial gastrectomy was performed to remove the non-viable tissue. Despite the operation, the patient’s condition deteriorated into irreversible shock, and she died of multiorgan dysfunction seven days after surgery. The authors note that immediate hemodynamic stabilization and urgent surgical intervention remain the mainstay of managing this catastrophic condition, a conclusion drawn from their own experience and from the published literature they reviewed.

The rarity of the case is central to its significance. The stomach is characterized by a rich vascular supply that forms an extensive network of collateral anastomoses, which is why gastric ischemia and gangrene are so uncommon. The celiac trunk and its branches supply the stomach through the right and left gastric arteries, which feed the lesser curvature, and the right and left gastroepiploic arteries, which supply the greater curvature. This supplying system is not only extensive but also highly variable between individuals. According to the literature the authors reviewed, the areas most often affected by ischemia are the greater curvature, the posterior wall and the fundus, which mirrors the distribution seen in this case, while the cardia, antrum, lesser curvature and anterior gastric wall are less frequently involved.

The report situates the case within a broader discussion of what can compromise gastric blood flow in children. Increased intragastric pressure above 20 cm H2O can disturb gastric blood flow and displace the lower esophageal sphincter, impairing vomiting and further aggravating the pressure; such findings have been described in patients with bulimia, anorexia nervosa, Prader-Willi syndrome, aerophagia and psychogenic polyphagia, and one report described the occurrence after a single binge-eating episode without associated psychiatric illness. Gastric ischemia can also result from gastric volvulus, either primary or secondary to diaphragmatic hernias, with possible perforation, and congenital diaphragmatic hernia can contribute through a bottleneck effect causing incarceration, ischemia and perforation. Other reported causes include infectious gastritis, ingestion of corrosive agents, and thromboembolism or occlusion of the major arterial supply.

Substance use is a further recognized mechanism. According to the report, benzodiazepines, cocaine, cannabinoids and cannabis can induce severe vasospasm and vascular injury leading to thrombosis, and cannabis in particular can delay gastric emptying. Although cannabis and cannabinoid ingestion rarely leads to gastrointestinal ischemia, the authors conducted a literature search across PubMed/MEDLINE, Embase, Scopus, Web of Science and Google Scholar from database inception to 2026, combining cannabinoid terms with terms for gastrointestinal vascular injury. They included peer-reviewed human case reports or series reporting acute gastrointestinal ischemia, necrosis or perforation associated with cannabinoid use with complete data on affected organ sites, management and clinical outcomes, and excluded cases driven by alternative mechanical or primary vascular etiologies. Among the published cases summarized in their table, one unique report described how chronic intake of cannabis sativa in large quantities could lead to severe gastric dilation and thus ischemia. It remains unclear from the report which, if any, of these mechanisms operated in the present case, since the exposure was undisclosed and the causal link between the toxicology findings and the gastric necrosis is presented as a consideration rather than a proven mechanism.

The authors also frame the case within the epidemiology of pediatric poisoning. In a report from the World Health Organization cited in the paper, acute poisoning accounts for an estimated 45,000 deaths annually among children and young people under the age of twenty years, with age and socioeconomic status among the factors that predict severity and outcome. Among substance abusers, an important aspect of neglect lies in the improper storage of illicit drugs. One study cited in the report showed that children living in households affected by maternal substance use disorder have more than double the risk of accidental drug poisoning compared to unexposed children. In a retrospective analysis covering children under six years of age from 2017 to 2021, another study found 7,043 reported cannabis exposures, with an upward trend in numbers over the period. These figures describe populations and trends rather than the circumstances of the present case, but the authors argue they accentuate the relevance of accidental ingestion as a pediatric hazard.

Clinically, the presentation of gastric ischemia varies widely depending on the underlying cause, whether acute gastric dilatation or substance ingestion, and the condition can lead to systemic and gastrointestinal decompensation if not recognized early. Typical presentations include hematemesis or vomiting and an acute abdomen, with examination usually revealing peritonitis in the form of abdominal tenderness, distension, rigidity and a silent abdomen on auscultation. Systemic signs usually include tachycardia, hypotension, respiratory distress and metabolic acidosis. Because of the rarity of the condition, the authors caution that it can be missed in routine investigations; abdominal X-ray findings range from non-conclusive images to gastric pneumatosis and pneumoperitoneum if perforation occurs, while computed tomography can provide more accurate radiological data. In the presence of hemodynamic instability or peritonitis, however, immediate surgical exploration is mandated. Early intervention begins with hemodynamic stabilization followed by definitive management of the underlying cause, with laparotomy remaining the mainstay. A well-demarcated perforation may be amenable to primary closure, whereas non-viable or gangrenous edges warrant partial gastrectomy, and in severe cases total gastrectomy. The stakes of delay are high: the authors cite a thirty-day mortality rate that can reach up to thirty percent, with a delayed one-year mortality rate of up to forty percent. As a single case report with an undisclosed exposure, the study cannot establish causation between the detected substances and the gastric necrosis, and the authors present substance-induced vasospasm as a consideration to keep in mind in suspicious conditions rather than a confirmed diagnosis.

Subject of Research: A fatal pediatric case of gastric ischemia and necrosis following accidental substance exposure

Article Title: Fatal pediatric gastric ischemia following accidental substance exposure; case report and review of literature

Article References: Ahmed, O. M., Khedr, S., Mahmoud, M., & Magdy, B. (2026). Fatal pediatric gastric ischemia following accidental substance exposure; case report and review of literature. Egyptian Pediatric Association Gazette, 74(1), Article 128. https://doi.org/10.1186/s43054-026-00628-y

Image Credits: AI Generated

DOI: 10.1186/s43054-026-00628-y

Keywords: gastric ischemia, gastric necrosis, pediatric emergency, case report, cannabis, benzodiazepines, toxicology screening, partial gastrectomy, laparotomy, multiorgan dysfunction, accidental poisoning, vasospasm