A 68-year-old male with neurogenic bladder requiring self-catheterization, atrial fibrillation on coumadin, and osteoarthritis on chronic ibuprofen presented with lower extremity weakness after a fall. He was found to have a supratherapeutic INR of 6.6 and temperature of 39°C. Laboratory work showed leukocytosis to 15.5 th/mm3 and urinalysis with 3+ leukocyte esterase and greater than 180 white blood cells. He was admitted for treatment of urinary tract infection and INR correction.
On day four of hospitalization, the patient developed left lower quadrant abdominal pain and nausea. Labs showed leukocytosis to 21.9th/mm3, a normal lactic acid, and negative blood cultures. CT of the abdomen revealed gastric distension, extensive air within the gastric wall and short gastric veins, and air within the ascending and transverse left portal venous branches without viscous perforation. These findings were consistent with emphysematous gastritis. The patient was started on vancomycin and piperacillin-tazobactam, bowel rest, and IV hydration. Upper endoscopy revealed erythematous, inflamed, and ulcerated mucosa of the gastric antrum and body. A non-bleeding ulcer was seen in the gastric fundus. Pathology was negative for Helicobacter pyloriand showed reactive glandular atypia.
The patient was discharged on pantoprazole 40mg twice daily and sucralfate 1 gram four times a day. A repeat endoscopy performed eight weeks later showed healing gastric ulcers in the fundus and body.
Discussion:
Emphysematous gastritis is a rare disorder with a 62% mortality rate that typically presents with epigastric abdominal pain, nausea, vomiting, and diarrhea. In more severe disease hemodynamic instability, hematemesis, and melena may also be present. This disease is likely caused by invasion of gas-forming microorganisms through the mucosal layer of the stomach. Typical organisms include the Clostridium species, Staphylococcus aureus, Pseudomonas aeruginosa, Candida albicans, and disseminated strongyloidiasis.
Predisposing factors include pancreatitis, adenocarcinoma, alcohol abuse, recent gastroenteritis, corrosive ingestion, chronic NSAID and steroid use, diabetes, COPD, and immunosupression. CT is considered the gold standard for diagnosis of emphysematous gastritis and typically shows a streak-like linear pattern of gas within the stomach wall and air within the biliary tract. In contrast, gastric emphysema, which is caused by mechanical introduction of air to the gastric wall, lacks the presence of portal venous air.
Recently, there has been a paradigm shift in the therapeutic approach of emphysematous gastritis. Previously, surgical intervention was considered the gold standard. However, recent reports suggest that conservative management with broad-spectrum antibiotics, IV hydration, and bowel rest can result in favorable outcomes. Our patient is a good example of how early diagnosis and prompt medical management can be successful in treating emphysematous gastritis.
Conclusions:
Emphysematous gastritis is a rare disorder with a 62% mortality rate. Recently, there has been a paradigm shift in the therapeutic approach of emphysematous gastritis. Previously, surgical intervention was considered the gold standard. However, recent reports suggest that conservative management with broad-spectrum antibiotics, IV hydration, and bowel rest can result in favorable outcomes. 