Emphysematous Gastritis: A More Recognized Complication in Diabetic Patients

Abstract

Emphysematous gastritis is a condition involving invasion of the gastric wall by gas-producing organisms. Previous relevant articles include case reports and a case review of 41 patients. Computed Tomography (CT) findings reveal a streaky and linear band of air with thickening of gastric wall in the setting of poorly controlled diabetes. Mortality can be as high as 62%, and early recognition with prompt delivery of broad-spectrum antibiotics is key in management. 24 year old white female presents with multiple admissions for abdominal pain. Medical history includes uncontrolled diabetes type 1, hypothyroidism, kidney disease, and prior peptic ulcer. CT Abdomen reveals extraluminal free intraperitoneal air in the left upper abdomen concerning for perforated ulcer. An EGD is performed, revealing an erythematous patch along the greater curvature. Biopsies show chronic inactive gastritis with mucosal hemorrhage without H. pylori. After 4 additional admissions within 60 days, a repeat CT Abdomen for abdominal pain reveals air in an edematous gastric wall with extensive intrahepatic portal venous gas. Meropenem is added, but there is persistence of abdominal pain and poor oral intake 18 days into admission. Repeat CT shows distended gastric lumen without wall thickening or definite pneumatosis. Repeat EGD shows a non-bleeding, 7x2cm necrotic ulcer in lesser curvature of stomach. Patient was taken to surgery for Roux-en-Y. Current knowledge of emphysematous gastritis is limited to case reports, with only one published textbook found. Predisposing factors include: diabetes, malignancy, alcohol, NSAID use, post-abdominal or pelvic surgery, and corrosive ingestion. Subsequent ischemia or necrosis permits gas-forming organisms to enter the gastric wall. CT findings include air presenting as streaky and linear consistency, which can be differentiated from gastric emphysema as the latter presents with round air bubbles. Management is geared by early recognition, broad spectrum antibiotics, and supportive care. Consider surgery when there is gastric perforation, or uncontrolled sepsis. The overall mortality is as high as 62%, and it is associated with gas-producing bacteria and fungi Emphysematous gastritis is a rare, but deadly complication in poorly controlled diabetic patients. Consider this condition when there is gastric thickening, linear or streaky air in wall on CT imaging. Management includes broad spectrum antibiotic and supportive care.