2671 Sparing the Knife: A Case of Emphysematous Gastritis Managed Conservatively

Abstract

INTRODUCTION: Emphysematous gastritis (EG) is a rare and obscure disease that carries a high mortality rate, whilst posing a diagnostic challenge. EG is caused by gas forming bacteria invading the gastric wall through disruptions in the mucosal barrier. Diagnosis is made with abdominal computed tomography (CT) scan demonstrating gas in the gastric wall. Traditionally EG has been managed surgically with partial gastrectomy, however recent case based studies support the role of conservative medical management in treating this aggressive disease. Here we present a case of non-surgically managed emphysematous gastritis. CASE DESCRIPTION/METHODS: A 28-year-old male with a history of uncontrolled type 1 diabetes mellitus (Hemoglobin A1c: 14.70) presented with a three-day history of diarrhea, melena, and orthostatic dizziness. Earlier that week the patient had been diagnosed with diabetic and initiated on metoclopramide. Despite stopping metoclopramide, the patient's diarrhea continued. Upper and lower endoscopy was performed and was largely unremarkable. The patient was discharged on erythromycin. The patient returned to the ED the following morning after developing severe abdominal pain. The physical examination revealed a soft abdomen with diffuse tenderness to palpation. Abdominal CT scan demonstrated emphysematous gastritis. Treatment was initiated with aztreonam, clindamycin, vancomycin, levofloxacin, and caspofungin. Within twenty-four hours, the patient improved clinically and repeat abdominal CT scan demonstrated significant improvement in gastric wall emphysema. After five days of broad-spectrum antibiotics the patient had complete resolution of abdominal pain. DISCUSSION: EG is a rare condition caused by gastric wall invading bacteria. Recently there has been a drastic shift in the preferred management strategy for this deadly condition that carries a mortality rate as high as 60%. A retrospective review demonstrated that prior to the year 2000 62.5% of patients with EG underwent surgical management, after 2000 this percentage dropped to 22.2%. In deciding on appropriate regimens, it is important to have broad coverage for gram-negatives, anaerobes, and fungi. Despite the lethality of EG, our case contributes to the growing body of literature that suggests that with early diagnosis and initiation of broad spectrum antibiotics, patients can be spared operative management and have successful recovery.