Cocaine can cause severe gastrointestinal ischemia through vasoconstriction, endothelial injury, and thrombosis. Gastric necrosis is exceptionally rare because the stomach has a rich collateral blood supply.

A 42-year-old man with confirmed recent cocaine exposure was admitted after a prolonged out-of-hospital cardiac arrest attributed to toxic rhabdomyolysis and severe hyperkalemia. Persistent fever and enteral feeding intolerance preceded abdominal pain. Contrast-enhanced computed tomography showed pneumoperitoneum, poor enhancement of the greater curvature, and an abdominal wall abscess. Surgery identified perforated extensive gastric necrosis and thrombosis of the right gastric artery and gastroepiploic arcade. Approximately four fifths of the stomach were resected, and continuity was restored by Roux-en-Y gastrojejunostomy. Histology confirmed full-thickness gastric necrosis. The postoperative course was complicated by collections, wound dehiscence, vomiting, severe weight loss, and transient gastrojejunal anastomotic narrowing requiring endoscopic dilation and nasojejunal nutrition. After discharge to medical respite, he returned the next day after a probable repeat suicide attempt and remains lost to follow-up.

The vascular findings and substantial cocaine exposure support cocaine-associated ischemia, probably aggravated by the prolonged low-flow state. Resuscitation-related gastric distension and unrecognized caustic exposure were considered but were less consistent with the overall findings. Persistent unexplained fever and feeding intolerance delayed abdominal imaging and may have allowed the necrosis to progress.

Cocaine-associated gastric ischemia should be considered when critically ill patients have unexplained fever, abdominal symptoms, or feeding intolerance. Early imaging may limit resection; coordinated psychiatric, addiction, and social follow-up is essential in vulnerable patients.