Hepatobiliary and Pancreatic: Emphysematous gastritis with hepatic portal venous gas

Abstract

A woman, aged 41 years, was admitted to hospital with acute epigastric pain and abdominal distension. She was known to have ischemic heart disease, hypertension, hyperlipidemia and diabetes and had been previously diagnosed with a sliding hiatus hernia. Her medication at the time of admission included pantoprazole, rosuvastatin, ramipril, metformin and aspirin. On physical examination, there was moderate tenderness on palpation in the epigastrium. Blood tests revealed an elevated white cell count (15.6 × 109/L) with a neutrophilia but other blood tests including an amylase and lipase were within the reference range. A plain abdominal radiograph showed a distended stomach while a computed tomography (CT) scan showed gas within the branches of hepatic portal vein (arrows) and gas in the posterior wall of the stomach (arrows) consistent with emphysematous gastritis (Figure 1). At upper gastrointestinal endoscopy, there was a well-demarcated area of erosive gastritis on the posterior wall of the body of the stomach (Figure 2). She was treated with intravenous fluids and an intravenous proton pump inhibitor and this was followed by a relatively rapid improvement in her symptoms. A repeat CT scan after 1 week showed resolution of hepatic portal venous gas and repeat endoscopy after 3 weeks showed almost complete resolution of gastritis. Emphysematous gastritis is a rare disease characterized by the presence of gas in the wall of the stomach, usually shown on a CT scan. Bacteria associated with emphysematous gastritis have included Clostridium welchii, Streptococcal species, Escherichia coli, Enterobacter species and Staphylococcus aureus. Common predisposing factors include the ingestion of corrosive substances, alcohol abuse, abdominal surgery, diabetes and immunosuppression. Some of these patients have gas in hepatic portal veins. This is usually most prominent near the periphery of the liver in contrast to air in the bile ducts (pneumobilia) that is usually more prominent in and around the hilum of the liver. Because of presumed gastric infection, most patients are treated with broad-spectrum antibiotics. Early complications include gastric perforation and some patients have been treated with gastric surgery. Mortality rates as assessed by case reports appear to be at least 50%. In the above patient, gastritis was restricted to a segment of the stomach and the patient made a spontaneous and apparently complete recovery. Contributed by