Emphysematous gastritis

Emphysematous gastritis

49 year-old diabetic female with severe abdominal pain, nausea & vomiting, fever and leukocytosis.

case-image
case-image
case-image
case-image

Observation and interpretation

CECT abdomen reveals:

  • Over-distended stomach with gastric wall thickening and extensive streak-like, curvilinear intramural gas within the gastric wall (red arrows).
  • Air lucencies with the liver in portal distribution (yellow oval).
  • Multiple free air foci anterior to liver (yellow arrow) and along left crus of diaphragm.
  • Minimal free fluid in sub-hepatic and peri-splenic regions.
case-image
case-image

Principal Diagnosis

Emphysematous gastritis with pneumoperitoneum and portal venous gas

Differential Diagnosis

  • Gastric emphysema
  • Ingestion of caustic substances
  • Ischemia
  • Gastric ulcer perforation
  • Iatrogenic & traumatic causes

Further Management

  • Urgently inform the referring clinician.
  • Medical management is considered the therapeutic option – intravenous fluid resuscitation, antibiotics.
  • Surgery reserved for failed conservative management and in patients who develop signs of peritonitis.

Teaching Points

  • Emphysematous gastritis is caused due to gas forming bacteria within the stomach mucosa (Klebsiella, E. coli, Clostridium, Enterobacter, Pseudomonas).
  • It is associated with Diabetes, alcoholism,  gastroenteritis, long-term use of corticosteroids, recent abdominal surgery and caustic ingestion.
  • CT is considered the preferred imaging modality to diagnose intramural gastric air.

References

  1. Jeong MJ. Emphysematous gastritis: Impressive radiological findings. Radiol Case Rep. 2022 Sep 9;17(11):4257-4259. doi: 10.1016/j.radcr.2022.08.046. PMID: 36120522; PMCID: PMC9471968.
  2. Yalamanchili M, Cady W. Emphysematous gastritis in a hemodialysis patient. South Med J 2003;96(1):84-88.
  3. López-Medina G, Castillo Díaz de León R, Heredia-Salazar AC, et al. Gastric emphysema, a spectrum of pneumatosis intestinalis: a case report and literature review. Case Rep Gastrointest Med 2014;2014:891360.
  4. Kussin SZ, Henry C, Navarro C, et al. Gas within the wall of the stomach: report of a case and review of the literature. Dig Dis Sci 1982;27:949-954.
  5. Riaz S, Kudaravalli P, Saleem SA, Sapkota B. Emphysematous Gastritis: A Real Indication for Emergent Surgical Intervention? Cureus. 2020 May 13;12(5):e8106. doi: 10.7759/cureus.8106. PMID: 32426198; PMCID: PMC7228801.
  6. Nasser H, Ivanics T, Leonard-Murali S, Shakaroun D, Woodward A. Emphysematous gastritis: A case series of three patients managed conservatively. Int J Surg Case Rep. 2019;64:80-84. doi: 10.1016/j.ijscr.2019.09.046. Epub 2019 Oct 7. PMID: 31622931; PMCID: PMC6796715.
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