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Gastric emphysema

Case contributed by Jayanth Keshavamurthy
Diagnosis almost certain

Presentation

KUB radiograph was obtained for abdominal pain, followed by CT scan of the abdomen.

Patient Data

Age: 80 years
Gender: Male
x-ray

Mottled gas overlying the stomach.

ct

Intramural gas in the dependent posterior wall of the stomach.

Left-sided hydroureteronephrosis and right renal multiple stones.

Important pertinent negatives that need mentioning are:

  1. absence of free peritoneal air

  2. absence of portal venous gas

  3. absence of pneumatosis intestinalis or mediastinal emphysema

  4. no NG tube and no history of gastroscopy

Gastroenterology and/or surgery consult important to monitor clinical progress as it is not possible to differentiate emphysematous gastritis from the more benign gastric emphysema.

Urinary tract calculi and hydronephrosis require further investigation.

Esophagogastroduodenoscopy (EGD) findings:

Esophagus: Esophageal mucosa was normal, with Z-line at 45 cm.

Stomach: A large amount of bile was seen in the stomach. The gastric mucosa was diffusely erythematous without evidence of perforation. Some mosaic pattern was seen, suggestive of portal hypertensive gastropathy. No biopsies were obtained.

Duodenum: Normal duodenal mucosa.

Case Discussion

So far the patient has been managed conservatively. The patient is doing well even a few weeks later.

Possible causes of gastric emphysema include:

  • transient ischemia due to local or systemic hypoperfusion

  • mucosal breach due to instrumentation or ulceration, or due to increased intra-gastric pressure (e.g. from forceful vomiting or gastric outlet obstruction)

  • infection by gas-forming organisms (emphysematous gastritis), in which case the patient is seriously ill and CT may show portal venous gas

  • spread of mediastinal gas

Given the clinical features and CT appearances, the likely etiology in this case is transient gastric ischemia. This is unusual due to the stomach’s rich arterial supply.

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