Emphysematous Gastritis After Endoscopy: A Case Report

Abstract

Emphysematous gastritis (EG) characterized by air within the gastric walls, results from invasion of mucosa by gas-forming microbes. Despite being first reported in 1989, there are only a few articles addressing the incidence, management and follow up of such cases due to its rarity. We describe a case of EG in a patient who presented with epigastric pain, vomiting and melena for a day after undergoing endoscopy. A 27 year old male with a medical history significant for diabetes and gastroparesis presented with epigastric pain, vomiting and melena for a day after undergoing endoscopic evaluation for diarrhea of 2 weeks. On examination, he was febrile, hypotensive, tachycardic and had generalized rebound tenderness of abdomen. His laboratory tests revealed a white blood cell count of 12100 cells/uL with 85% neutrophils, hemoglobin 5.8 gm/dl, pH 7.29 and anion gap of 18 with lactate of 3.60. Computed tomography (CT) of the abdomen showed gastric wall emphysema and gas within portal veins consistent with EG (Figure A and B).He was conservatively managed with levofloxacin, aztreonam, clindamycin and caspofungin. His symptoms subsided and repeat CT in 2 days showed significant improvement. Per oral antibiotics were continued for a total of 14 days. He remained asymptomatic in subsequent clinic visit and underwent a follow up endoscopy in 3 weeks with findings of normal gastric mucosa. EG could be a fatal condition with mortality reaching 60%. Streptococci, Escherichia coli and several other gas forming organisms are implicated. Conditions that disrupt the gastric mucosal defenses such as ingestion of corrosive substances, diabetes mellitus and immunosuppression and in our case endoscopic biopsy can facilitate the microbial invasion of the gastric wall. It should be differentiated from gastric emphysema, which is a self-resolving, benign, non-infective condition. EG should be promptly treated with bowel rest and antibiotics covering gram negative, anaerobic and fungal organisms. Physicians should be cognizant of this rare condition to facilitate early diagnosis and prompt treatment to reduce the high mortality associated with it.2624_A Figure 1. Gastric wall emphysema with gas within surrounding stomach veins and portal vein.2624_B Figure 2. Gastric wall emphysema with gas within surrounding stomach veins and portal vein.