Emphysematous gastritis: A case series of three patients managed conservatively

Abstract

Introduction: Emphysematous gastritis (EG) is a rare condition characterized by air within the gastric wall with signs of systemic toxicity. The optimal management for this condition and the role of surgery is still unclear. We here report three cases of EG successfully managed non-operatively.

Presentation of cases: All three of our patients were elderly females with several co-morbidities. The chief presenting symptom was abdominal pain with signs of systemic toxicity ranging from tachycardia and hypotension to acute kidney injury. Computed tomography (CT) scan revealed gastric pneumatosis in all patients. One patient had extensive portal venous gas, and another had free intraperitoneal air. All patients were managed with nothing by mouth, proton pump inhibitors, intravenous fluid resuscitation, and antibiotics. Repeat CT scan in two patients in 3-4 days demonstrated resolution of the pneumatosis. They were all discharged home tolerating an oral diet.

Discussion: The presentation of EG is non-specific and the diagnosis is primarily established by findings of intramural air in the stomach on CT scan. The initial management of EG should be nothing by mouth, proton pump inhibitor, intravenous fluid resuscitation, and antibiotics with surgical exploration only reserved for cases that fail non-operative management, demonstrate clinical deterioration, or develop signs of peritonitis.

Conclusion: Early recognition and initiation of appropriate therapy is crucial to prevent the progression of EG. EG, even in the presence of portal venous air or pneumoperitoneum, should not represent a sole indication for surgical exploration and trial of initial non-operative management should be attempted when clinically appropriate.

Keywords: Case series; Computed tomography; Emphysematous gastritis; Gastric emphysema; Gastritis.

Fig. 1

Non-contrast computed tomography scan of the abdomen revealed gastric distention and gastric pneumatosis throughout the wall of the stomach.

Fig. 2

Computed tomography scan of the abdomen showing resolution of the gastric pneumatosis after 4 days.

Fig. 3

Non-contrast computed tomography scan on presentation revealing gastric pneumotosis and extensive portal venous gas.

Fig. 4

Computed tomography scan of the abdomen with contrast three days after the first scan showing resolution of the gastric pneumatosis and portal venous gas.

Fig. 5

Computed tomography scan of the abdomen (lung window) showing extensive gastric pneumatosis and free intraperitoneal air superior to the liver (circle).