Concomitant Intramural Stomach and Portal Venous Gas: A Case Report

Abstract

Purpose: An 82-year-old female originally with a PMH of Afib not on anticoagulation, colon cancer, and uterine cancer, presented to our ER with abdominal discomfort, nausea, and five episodes of bilious vomiting. She did not have any constipation or diarrhea, and her last bowel movement was a day prior to presentation. Her vitals in the ER showed tachycardia and hypotension. Physical exam revealed a tender abdomen with rebound. Labs including ACP, Chem-7, coagulation studies and CXR were all within normal limits. CBC showed leukocytosis and occult blood was positive. CT abdomen showed intrahepatic portal venous air with circumferential intramural air within the proximal-mid stomach consistent with emphysematous gastritis (EG) with no evidence of SBO. She was started on IV hydration, empiric antibiotics and kept NPO. Surgery was consulted. Her hospital course was better than predicted. Her vitals improved with hydration and broad spectrum antibiotics. On day 5, CT abdomen was repeated which showed interval resolution of EG and portal venous gas. She was started on a dysphagia diet on day 6, gradually advanced and discharged home on day 9. Discussion: Gas in the gastric wall is a rare finding associated with a high mortality rate of 50%. Different etiologies include gastric outlet obstruction, damage from instrumentation, extensive CPR, ulcers, steroids, and caustic ingestion. The presence of gastric dilatation with gastric and portal venous air on CT narrows the differential to two main diseases with very different symptoms and prognosis. EG must be differentiated from gastric emphysema early in order to avoid adverse outcomes. EG has concomitant air in the portal venous system and presents acutely in a hemodynamically unstable person as opposed to gastric emphysema which is usually asymptomatic and incidentally found on imaging with air only in the stomach. EG is a severe and rare form of gastritis due to invasion of gas producing organisms, with late complications including strictures and perforations. Early diagnosis and non-operative management with IV hydration and broad spectrum antibiotics is imperative for a preferred outcome.Figure