• Hiroyuki Yamamoto and Toru Hashimoto.
• Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, Chiba, Japan.
• Medicine (Baltimore). 2023 Feb 3; 102 (5): e32842e32842.

RationaleAtherosclerotic chronic mesenteric ischemia (CMI) is caused by stenosis or occlusion of mesenteric arteries and can progress to potentially life-threatening acute mesenteric ischemia if left untreated. However, correct diagnosis and timely treatment remain a challenge due to a lack of awareness, variable symptoms, and inconclusive diagnostic testing.Patient ConcernsAn 82-year-old man with multiple cardiovascular risk factors, including chronic kidney disease, presented with dyspnea, anorexia, and oliguria. Laboratory results revealed severe renal dysfunction (raised serum blood urea nitrogen of 83.8 mg/dL, serum creatinine levels of 8.20 mg/dL, and decreased estimated glomerular filtration rate of 5.5 mL/min/1.73 m 2 ), hypoalbuminemia, and moderate anemia. A provisional diagnosis of acute exacerbation of chronic kidney disease was made and the patient required tentative intermittent hemodialysis, received blood transfusions, and was eventually placed on maintenance hemodialysis. However, the patient's symptoms did not improve. Esophagogastroduodenoscopy (EGD) revealed longitudinal gastric ulcers on the anterior and posterior walls of the stomach, which were named "a gastric double-stripe sign" because the lesions corresponded to the watershed areas of the stomach. No Helicobacter pylori infection or malignancy was identified, and increasing the dose of lansoprazole had no beneficial effects. Doppler ultrasound revealed high peak systolic velocity (270 cm/s) of the celiac artery (CA), suggesting CA stenosis, which was confirmed by magnetic resonance angiography.DiagnosisFinal diagnosis of CMI was made based on patient's symptoms, EGD findings, Doppler ultrasound, and magnetic resonance angiography.InterventionsEndovascular revascularization for CA stenosis was performed.OutcomesThe patient obtained symptomatic relief concomitant with the resolution of the gastric ulcers. The post-procedural course of the patient was uneventful and he remained healthy at the 1-year follow-up.LessonsThis is the first case of CMI with EGD finding of a gastric double-stripe sign specific for gastric ischemia. This case highlights the clinical importance of this endoscopic finding in patients with suspected atherosclerotic CMI.Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.

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