3234 Unique Case of Gastroenteritis Presenting as Pneumatosis Intestinalis With Emphysematous Gastritis and Portal Vein Gas: Do Not Take Gastroenteritis Lightly

Abstract

INTRODUCTION: Pneumatosis intestinalis (PI) refers to presence of multiple thin gas filled cysts in the wall of gastrointestinal tract. It is a uncommon entity and can involve any site from stomach to the rectum. Isolated stomach involvement is very rare. PI can represent a wide spectrum of diseases with variable prognosis. CASE DESCRIPTION/METHODS: An 87-year-old male presented with multiple episodes of non-bloody watery diarrhea associated with nausea and epigastric pain for 2 days. He has past medical history of hypertension, hyperlipidemia and coronary artery disease with bypass surgery. Denied any fever, vomiting, sick contact, recent travel or chest pain. On physical exam, blood pressure was 146/90 mmgh, pulse rate 90/min, respiratory rate 20/min with temperature of 100.5 F. The abdomen was diffusely tender with hypoactive bowel sounds without rebound tenderness or guarding. The laboratory findings showed normal blood counts except leukocytosis of 14000/ml, elevated urea levels of 30 mmol/L, creatinine levels of 1.4 mg/dl and potassium of 3.5. A CT abdomen/pelvis with contrast showed air in gastric wall and air in portal vein which was concerning for emphysematous gastroenteritis. Further work up came back negative including blood cultures, stool studies, clostridium difficile and lactic acid levels. He was admitted to ICU and evaluated by surgeon, Gastroenterology and Infectious disease specialist. Patient was made nothing per oral, received intravenous fluids and IV antibiotics including Ciprofloxacin and Metronidazole. With no other exact cause of PI, the patient's presentation was ultimately thought to represent a mild bacterial infection yielding minimal clues to the definitive diagnosis aside from radiographic data. The patient actually did very well with conservative management and was discharged on antibiotics after a few days with plan to follow up with an outpatient CT scan. DISCUSSION: Emphysematous gastritis with air in portal vein is very rare with underlying gastroenteritis, a worldwide very common disease. It can be easy to miss especially if presentation is benign. This is extremely rare and can easily mimic viral gastroenteritis. High index of suspicion with low threshold of scan can be lifesaving.