A Rare Case of Emphysematous Gastritis - Sarcina Ventriculi

Abstract

Emphysematous gastritis (EG) is a type of gastritis with characteristic features of gas along the gastric wall. The common organisms associated with EG are Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa. It is considered to be a severe variant of Phlegmonous gastritis. A 65-year-old male with multiple comorbidities presented to the emergency room with abdominal pain, nausea, vomiting and cough for three days. Denied any history of corrosive ingestion, non-steroidal anti-inflammatory drugs, melena, hematochezia and trauma. On admission, he was afebrile, tachycardic (130), tachypneic (22), blood pressure 126/88 mmHg. Physical examination was positive for confusion, abdominal distension and epigastric tenderness. Laboratory examination revealed a white count 21.4 cells/dl, Hemoglobin 14.0 g/dl, platelets 350 cells/dl, INR 1.21, sodium 140 meq/l, potassium 4.2 meq/l, chloride 101 meq/l, bicarbonate 22 meq/l, blood urea nitrogen 30 mg/dl, creatinine 1.4 mg/dl, procalcitonin of 0.84 ng/dl. KUB X-ray was significant for gastric emphysema, Computer tomography (CT) abdomen demonstrated marked distention of the stomach with pneumatosis, consistent with EG and hepatic portal venous gas. He was empirically treated with broad-spectrum antibiotics. Esophagogastroscopy demonstrated few clean based ulcers at gastroesophageal[GE] junctions and bluish discoloration just distal to GE juntion suggestive of ischemic gastritis. Histopathology demonstrated reactive gastric epithelium due to Sarcina Ventriculi gastritis. Given his co-morbidities family opted for the hospice. Sarcina ventriculi is a gram positive anaerobic, sugar fermenting and spore forming organism.It is very difficult to culture in laboratory. The characteristic morphological features are basophilic staining, cuboid shape arranged in tetrad packets near the mucosal surface. The mechanism of injury is uncertain. It is considered delayed gastric emptying and carbohydrate stasis in association with acidic content of gastric juices provides an ideal culture medium. The by-products of the fermentation could induce the stomach and duodenal injuries. EG with S.ventriculi is most invariably fatal. CT abdomen is the most useful initial investigation followed by gastric biopsy as a confirmatory test. Regardless of the biopsy report it is prudent to start treating with broad-spectrum antibiotics and supportive therapy when EG is suspected, as early and aggressive treatment is the key to the prognosis.1919_A Figure 1. CT Abdomen- pneumatosis and portal venous air.1919_B Figure 2. Gastric mucosa with basophilc stained sarcina ventriculi arranged in tetrads.1919_C Figure 3. EGD demonstrating retained food material with bluish discoloration distal to the GE Junction