A Case of Gastric Emphysema: Incidental Findings or Serious Illness

Abstract

Gastric emphysema (GE) or gastric pneumatosis is a rare entity defined as air within the gastric wall. Etiologies include pneumothorax, instrumentation, infection, gastric wall ischemia, and mechanical injury. Several theories exist as to how the air disrupts the integrity of the gastric wall. These include a bacterial infection with Clostridium species and other gas-forming aerobic colonic bacilli, instrumentation with direct submucosal gastric wall injury, mechanical injury following increased intra-abdominal pressure, penetrating air through the mediastinum from increased intrapulmonary pressure or, gastric wall ischemia, which may be secondary to an underlying process. The diagnostic test of choice is CT of the abdomen. A hypodense linear fringe on the gastric wall is seen in GE, associated with gastric distention without thickening. In emphysematous gastritis, there is gastric wall thickening. There are no standardized guidelines for GE, but most cases have a good prognosis with a spontaneous resolution with conservation treatment. However, emphysematous gastritis management requires aggressive treatment due to the mortality rate of emphysematous gastritis approaching 60%. Patients are often considered for surgical intervention with total gastrectomy, given that active infection could delay or prevent healing. It is imperative to differentiate GE and emphysematous gastritis and understand the underlying pathogenesis as clinical outcomes are vastly different.

Emphysematous gastritis

“…The differentiation between emphysematous gastritis and gastric emphysema can be challenging but is important as clinical outcomes are totally different and indication for surgical treatment can vary. 5 Recent studies reported on the successful conservative treatments including fluid resuscitation, broad-spectrum antibiotics, bowel rest, fluid hydration and total parenteral nutrition. Surgical removal of the ischaemic gastric area by total gastrectomy or partial gastrectomy may be considered for patients with evidence of transmural ischemia, peritonitis or haemodynamic instability despite appropriate resuscitation.…”