Massive gastric pneumatosis from pyloric stenosis

Abstract

A 12-week-old infant presented with a one-day history of increased vomiting and lethargy. Gastroesophageal reflux had been diagnosed when he was four weeks old, but the symptoms had not lessened, despite a change of formula. The infant was severely dehydrated and had gastric distension, a decreased level of consciousness and gasping respirations. There was no abdominal tenderness. He was resuscitated with tracheal intubation and intravenous fluids. A plain radiograph showed massive gastric pneumatosis (Figure 1). Blood test results showed hypochloremic metabolic alkalosis. Ultrasonography suggested hypertrophic pyloric stenosis. The patient was stabilized, and a nasogastric tube was inserted for decompression. At the time of pyloromyotomy five days after admission, he had a markedly hypertrophied pylorus, and pneumatosis was still palpable in the stomach wall. The infant was discharged home in good condition four days after surgery.Fraenkel first described the unusual presentation of air within the wall of the stomach in 1889.1 The condition can be noninfectious (gastric pneumatosis) or infectious (emphysematous gastritis). The mortality rate for gastric pneumatosis is 41% in adults and 6% in children.2 Gastric pneumatosis is caused by a disruption of the gastric mucosa, which results in air dissecting into the stomach wall. This disruption typically results from gastric outlet obstruction caused by pyloric stenosis (as in this case), duodenal stenosis 3 or tumours; it can also result from protracted vomiting, instrumentation or tracking of air through the mediastinum or the pneumothorax. Pyloric stenosis is the most common cause of intestinal obstruction in infants.Emphysematous gastritis refers to mucosal disruption caused by gas-forming bacterial invasion. An antecedent gastric mucosal injury may allow infiltration of the bacteria. Causes in infants include necrotizing enterocolitis, caustic ingestion, recent abdominal surgery or gastroenteritis.4 These patients present with fever, appear unwell and have laboratory evidence of leukocytosis.This article has been peer reviewed.Competing interests: None declared.

Excessive Bright Echoes Sign for Hypertrophic Pyloric Stenosis Suggest the Diagnosis: Gastric Pneumatosis and Portal Venous Gas in Infants Suggest HPS

“…There have been a few reports of HPS cases in the surgical and radiologic literature, demonstrating either air within the gastric wall or portal venous air, but we found that the combination of both findings is particularly helpful to steer the imager toward considering HPS.…”

“…In emphysematous gastritis, mucosal disruption is due to gas‐forming bacteria, perhaps aided by earlier injury to the mucosa, which can be seen in cases of necrotizing enterocolitis, caustic ingestion, and recent abdominal surgery. Gastric pneumatosis is thought to result from increased intraluminal pressure from gastric outlet obstruction, which causes air to dissect into the stomach wall . On sonography, gastric pneumatosis is seen as bright echoes in the gastric wall.…”

Pneumatosis intestinalis presenting as pneumoperitoneum in a teenage girl with pyloric stenosis

“…There are only a few isolated case reports. It has been reported that pyloric stenosis may contribute to massive gastric pneumatosis 6 7. However, the described patients were of infantile age and the pneumatosis was localised in the stomach wall.…”

Intramural gas in stomach along with acute calculus cholecystitis: an unusual association

“…It may be intraluminal air entering the stomach wall from gastric lumen through the disruption of mucosa. This disruption may be caused by either iatrogenic injury during upper gastrointestinal procedures like endoscopy3 or nasogastric tube placement4 or by increased intraluminal pressure secondary to pyloric or enteral stenosis 5. Gastric paresis is also known to be associated with gastric emphysema 6.…”