Interesting case of gastric emphysema

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A 56‐year‐old woman was presented to the emergency department with colicky epigastric pain on a background of diarrhoea and vomiting. An endoscopy 18 months earlier for symptomatic reflux had shown mild gastritis but was negative for Helicobacter pylori.
Past medical history included systemic lupus erythematosus for which she was on regular prednisolone and Hashimoto's thyroiditis. A computed tomography (CT) organized by her general practitioner showed a thin layer of gas tracking along the gastric wall at the fundus and proximal body of the stomach (Fig. 1). There was no associated free intraperitoneal gas.
On examination, she was apyrexial and haemodynamically stable, with moderate tenderness to palpation in the epigastrium. A provisional diagnosis of gastric emphysema was made and the patient was treated conservatively with nasogastric aspiration, parenteral alimentation, broad spectrum antibiotics and proton pump inhibitor therapy. A repeat CT scan on day 11 of admission showed resolution of the emphysematous changes. An endoscopy performed during admission showed fundic gland gastric polyps but no ulceration. Biopsies revealed mild non‐specific changes only. Enteric feeding was reintroduced and she was discharged after a 14‐day admission.
The presence of air in the wall of the stomach is a rare and concerning clinical finding. It is most often associated with bacterial infection, distention secondary to gastric outlet obstruction, mucosal trauma following instrumentation, gastric ischaemia or dissection from the mediastinum. Rarely, it can present secondary to extensive cardiopulmonary resuscitation, vomiting, ulcers and steroids.1
There are four theories of how air enters the gastric wall.2
The condition could be further classified as gastric emphysema (intramural, interstitial or non‐bacterial), emphysematous gastritis (infective or bacterial) and cystic pneumatosis (pneumatosis cystoides intestinalis).3
Gastric emphysema is typically less severe and sometimes asymptomatic and often resolves spontaneously. Patients often present systemically well with mild to moderate symptoms including abdominal pain.4
Emphysematous gastritis, however, is a severe form of gastritis often due to a more sinister underlying cause resulting in significant morbidity and mortality described at 60–80%.4 This is likely due to invasion through the gastric wall by gas‐producing bacteria and patients present more unwell. This includes fever, nausea, vomiting/haematemesis and abdominal pain.
Differentiating gastric emphysema and emphysematous gastritis is made clinically and radiologically. Both will present with abdominal pain but the more severe pain, intractable vomiting, haemodynamic instability and rapid deterioration is hallmark of emphysematous gastritis. Early recognition of emphysematous gastritis is critical in reducing mortality.
The most sensitive imaging modality to distinguish the two in conjunction with clinical findings is a CT scan of the abdomen.5 This will show air in the stomach wall; however, in emphysematous gastritis, the air will usually have a cystic/mottled appearance and may be associated with portal venous gas. The stomach wall may be thickened and there may be intramural penetration of contrast. In gastric emphysema, the air will appear classically more linear and there may not be any concomitant gastric wall changes. CT is also useful to exclude associated pneumoperitoneum.5
Endoscopic findings can include submucosal bubbles of gas, necrosis, ulceration and erosions; however, our case showed only mild non‐specific changes supporting the likely diagnosis of gastric emphysema.6
Endoscopic ultrasound for investigation of gastric emphysema has been described and can demonstrate submucosal gas patterns and allows visualization of the gastric wall.2
There is no standardized treatment protocol available for the management of gastric emphysema. The prognosis is usually benign and resolution of the emphysema usually occurs within 72 h. Conservative management is most commonly recommended. The incidence of this condition has not been quantified as only a small number of case reports have been published since it was first described in 1895.
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