A Rare Case of Emphysematous Gastritis Secondary to Chemotherapy

Abstract

Emphysematous gastritis is a rare medical condition characterized by the presence of intra-mural air in the stomach associated with portal venous air tracking to a variable degree. There are no established guidelines favoring surgery over medical management. We present a case of a 64-year-old Caucasian male with a history of stage four colon adenocarcinoma with peritoneal carcinomatosis, malignant ascites, and liver metastasis status post-three cycles of chemotherapy who presented to the emergency room with complaints of generalized abdominal pain, nausea, non-bilious vomiting, and melena stools. He was managed conservatively as a case of sepsis secondary to emphysematous gastritis and made a full recovery. To our knowledge, this is the first reported case of emphysematous gastritis in an adult with colon cancer. Although we cannot establish a causal link between his chemotherapy regimen and emphysematous gastritis, the combined effect of an immunosuppressive state caused by advanced malignancy and cytotoxic effects of chemotherapy are the probable risk factors in our patient. We described the possible mechanisms of mucosal disruption by fluorouracil and bevacizumab in our case. Despite historically having a poor prognosis, emphysematous gastritis can be managed conservatively on a case-by-case basis. Clinicians should be aware that chemotherapy can be a predisposing factor to developing this rare condition.

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

“…7 If radiological findings do not aid in distinguishing the two, the clinical condition of the patient will likely point towards the correct diagnosis, as patients with emphysema tous gastritis are generally severely ill with signs of sepsis associated with bacterial translocation. 3,8 The role of oesophagogastroduodenoscopy (OGD) in diagnosis has not been established, as the diagnosis of emphysematous gastritis rests on clinical and radiological findings. 3 Whilst OGD may be considered to obtain tissue for microbiological analysis, particularly in treatment resistant cases, the lack of correlation between OGD appearances and the need for operative management, together with the risks of the procedure itself mean that routine OGD is not indicated.…”

“…3,8 The role of oesophagogastroduodenoscopy (OGD) in diagnosis has not been established, as the diagnosis of emphysematous gastritis rests on clinical and radiological findings. 3 Whilst OGD may be considered to obtain tissue for microbiological analysis, particularly in treatment resistant cases, the lack of correlation between OGD appearances and the need for operative management, together with the risks of the procedure itself mean that routine OGD is not indicated. 4 The diagnosis of emphysematous gastritis carries with it a poor prognosis with mortality rates reported to be as high as 60%.…”

“…Due to the rarity of this condition, (in 2021 there were fewer than 100 cases of emphysematous gastritis reported in English language literature 3 ) there is a paucity of evidence available to guide decision making around optimal management strategies.…”

“…The only evidence of abdominal upset after intubation and invasive ventilation, were the non-specific findings of rising lactate levels and progressively increasing NG aspirates, which prompted abdominal imaging. Most commonly, patients with emphysematous gastritis are found to have a leukocytosis, which has been reported as high as 67 × 10 9 /L 3 . To our knowledge, our case is the first reported example of emphysematous gastritis in the context of neutropenic sepsis.…”

“…12 The duration of treatment has not been well established, however a 7-day course has been described in successful cases. 4,8 Whether or not anti-fungal treatment should be added is another area of uncertainty, as there have been cases managed successfully which included 3,8,12 and omitted 4,12 it. As Candida species and polymicrobial infections account for 8.5% and 20% of organisms respectively, 2 a pragmatic approach would be to add empiric antifungal cover pending Beta-d-Glucan testing when there is concern of fungal sepsis.…”