Endoscopic ultrasonographic appearance of gastric emphysema

Abstract

Emphysematous gastritis (or phlegmonous gastritis) and gastric emphysema (or gastric pneumatosis) are variations of conditions associated with the presence of intramural air in the stomach. The presence of air in the gastric wall is a very rare clinical condition, associated with bacterial infection, increased intragastric pressure from gastric outlet obstruction, gastric mucosal disruption or air dissection from the mediastinum. In adults, this can occur in the setting of instrumentation-related injury, gastric outlet obstruction by gastric, duodenal or pancreatic malignancies or bowel ischemia. Here we describe a case of gastric emphysema related to repeated biliary stenting and partial duodenal obstruction in a patient with inoperable periampullary cancer, and provide the first description of the endoscopic ultrasonographic findings of gastric emphysema in the literature. In our case, endoscopic ultrasound showed a band of bright echogenicity arising from the submucosa layer, representing air in the gastric wall.

Figure 1

Abdominal sonography showing air in the gastric wall (arrow).

Figure 2

Endoscopic ultrasonography showing a band of bright echogenicity arising from the submucosal layer with shadowing (arrow), representing air in the gastric wall.

Figure 3

Abdominal computerized tomography revealing multiple liver metastases (white arrow), pneumobilia (thin arrow) and persistent air in the gastric wall (thick arrow).

Figure 4

Upper endoscopy showing diffuse erythema, edema, erosions and sloughing of the gastric mucosa.