2670 A Highly Lethal Case of Gastric Pneumatosis

Abstract

INTRODUCTION: While gas can accumulate in the intestinal wall at multiple sites, the stomach is the rarest site because of its acidity and very efficient mucosal barrier. In has been proposed in one retrospective study that 46% of their cases involved the colon, 27% the small bowel, 14% in whom the whole gastrointestinal tract was infected including the portal venous system, 7% the small bowel with the colon, and only 5% the stomach as in our case. CASE DESCRIPTION/METHODS: An 83 year old male with history of coronary artery disease, diabetes mellitus, bullous pemphigoid and smoking history presented for shortness of breath over one week. Patient was tachypnic and using accessory muscles on exam. During his hospital course, he had abdominal pain. CT Scan showed fluid filled distal esophagus, distended stomach, air-fluid levels and peripheral lucencies concerning for intramural gas. Nasogastric tube put out a large amount of red emesis after which he expired. DISCUSSION: There are two distinct pathological processes involved in air within the lumen of the stomach which is termed gastrointestinal pneumatosis. The first type is called gastric emphysema which often has a benign course and constitutes 9% of all gastrointestinal pneumatosis cases. Gastric emphysema is classified as traumatic, pulmonary or obstructive types. There have only been 5 recorded cases of gastric emphysema with a pulmonary etiology and four of those cases were secondary to bullous emphysema. The second type is emphysematous gastritis which involves gas forming organisms including Pseudomonas aeruginosa, Candida albicans, and Staphylococcus aureus. The risk factors for this dangerous type of gastrointestinal pneumatosis include a history of abdominal surgery or manipulation, bowel infarction/ischemia, immunosuppression which include disease processes including diabetes, alcohol abuse or corrosive material ingestion. There is a mortality of 16% in those receiving surgical treatment versus 6% who received only conservative treatment. In stable patients, improvement in clinical condition or emphysema resolution within 3 days occurs with nasogastric catheter decompression as attempted in our case. This becomes important in identifying between gastric emphysema, a relatively benign course, or emphysematous gastritis, which has a poor prognosis. As time becomes an increasingly prognostic factor for these individuals, differentiation in treatments based on type could lead to faster implementation which could ultimately help to prevent demise.