Emphysematous gastritis is a rare condition characterized by the presence of air in the wall of stomach because of invasion of gas forming organisms with mortality rates as high as 80%. We present a case of a 62‐year‐old male with a history of type II diabetes mellitus, alcoholism, intravenous drug abuse, hepatitis, and peptic ulcer disease with recent upper gastrointestinal bleeding revealing duodenal bulb ulcer on endoscopy, transferred from an outside hospital for treatment of spinal osteomyelitis. The patient's course was complicated by an acute change in mental status and abdominal distension. On exam, The patient was delirious, vitals of 95.4°F, blood pressure 70/50, heart rate 110 beats per minute, and tachypneic with 32 breaths per minute. Abdominal exam revealed a soft, mildly distended, tender abdomen, hypoactive bowel sounds, but no rigidity or rebound tenderness. Laboratory analysis showed hematocrit 29.4%, white blood cell count 12.6 K/μi, decreased platelet count to 89 K/μL (253 on admission), BUN/creatinine 148/5.1 with an anion gap of 20. a lactic acid level of 29 mEq/L, PTof 120 seconds. aPTT > 240 seconds, and INR of 1.7. Arterial blood gas revealed a pH of 6.95, PCO2 of 17 mm Hg, PO2 of 33 mm Hg, a HCO3 of 3.5 mEq/L. An abdominal CT scan revealed air in the gastric wall and hepatic portal venous gas. The patient was intubated for impending respiratory failure, and transferred to the intensive care unit. He was treated with aggressive fluid resuscitation, vasopressors, blood products, and broad‐spectrum antibiotics. Blood cultures and deep peritoneal lavage grew Klebsiella pneumoniae. Despite our besl efforts, the patient succumbed to septic shock with disseminated intravascular coagulopathy. Autopsy was deferred by patient's family.
Emphysematous gastritis, first described by Fraenkel in 1889, is a rare entity characterized by the presence of free air within the stomach wall and diffuse gastric wall inflammation. Only 51 cases have been reported in the literature since 1889. Ingestion of corrosives, alcohol abuse, recenl abdominal surgery, diabetes, and immune compromise are predisposing factors. In our case, we believe the patient's history of chronic alcohol abuse, diabetes, and recenl gastric manipulation (upper endoscopy) were predisposing factors to the development of this rare but life‐threatening, condition. The most commonly involved microorganisms include Streptococci, Escherichia coli, Pseudomonas aeruginosa, Clostridium perfringerts, Staphylococcus aureus, and mucormycosis. CT scan is the best imaging modality to diagnose this condition. Despite aggressive treatment measures, the prognosis in emphysematous gastritis is poor, with a staggeringly high mortality rate.
In conclusion, our case demonstrates an exceedingly rare condition that should be considered in the differential diagnosis of a patient with predisposing factors presenting with abdominal distension, altered mental status, and profound septic shock.
M. Singh, none; R. Reilly, none.