Emphysematous gastritis in a patient with neutropenic sepsis: A case report and literature review with comment on management

Abstract

Emphysematous gastritis is a severe form of gastritis caused by gas-forming infectious organisms and is most frequently encountered in critically unwell patients. Diagnosis rests on the radiographic appearances of air within the gastric wall, which may extend into the portal venous system. Not previously described in the context of neutropenic sepsis, our case involves a 77-year-old patient with emphysematous gastritis who was admitted to the intensive care unit with a neutrophil count of 0.1 × 10⁹/L and managed successfully with conservative treatment. Presenting complaints usually include abdominal pain, nausea, vomiting and occasionally haematemesis, in the context of systemic upset. Predisposing factors may include diabetes and immunosuppression, ingestion of corrosive substances, alcohol abuse, and abdominal surgery. The historical approach to management which previously involved urgent exploratory laparotomy with gastrectomy, has largely been replaced with conservative therapy, including broad-spectrum antimicrobials, gut rest and parenteral nutrition, with improved outcomes. Previously considered a commonly terminal diagnosis with mortality rates as high as 60%, this recent shift in approach to management has contributed to mortality rates being halved. The role of oesophago-gastro-duodenoscopy has not been established and is unlikely to be indicated in every case. Longterm complications may be of concern and include fibrosis and gastric contractures.

Keywords: Emphysematous gastritis; chemotherapy; gastric emphysema; gastric intramural air; neutropenic sepsis.

Figure 1.

(a) The first post intravenous contrast CT demonstrates diffuse intramural gas (white arrowheads) with translocation/perforation into the gastrohepatic ligament (yellow arrow) and into portal vein tributaries along the left gastric supply (red arrowhead). (b) Bottom left picture demonstrates portal vein gas lying peripherally in the liver in both lobes (orange arrows). (c) Bottom right picture is an oblique coronal minimum intensity projection which demonstrates the detail of intramural locules of gas on the stomach (green arrowhead) and beneath the mucosa of the duodenal cap (blue arrowhead).

Figure 2.

Follow-up non-contrast CT which demonstrates a collapsed stomach without intramural gas and resolution of the hepatic portal venous gas.