S2981 Emphysematous Gastritis: An Uncommon Cause of Acute Abdomen

Abstract

INTRODUCTION: Emphysematous gastritis (EG) is defined as air within the gastric wall leading to inflammation and systemic compromise. It is often caused by gas-forming microorganisms. Malignancy, bowel obstruction, excessive steroid use, chemotherapy, nonsteroidal anti-inflammatory drugs, and perforated ulcers can all lead to EG. We report the case of a male who presented with peritonitis and septic shock in the setting of intramural air in the stomach. CASE DESCRIPTION/METHODS: An 83-year-old male with history of congestive heart failure, diabetes mellitus, hypertension, and hyperlipidemia presented with diffuse abdominal pain for 2 days. On presentation, the patient was tachycardic, tachypneic, and hypotensive. Initial Laboratory values are shown in table 1. Examination revealed a rigid abdomen with guarding and rebound tenderness. He was started on IV norepinephrine to maintain blood pressure. NG tube was placed which produced 1.5 L of dark fluid. CT angiogram of abdomen illustrated intraperitoneal free air and evidence of pneumatosis within the fundus and posterior wall of the body of the stomach (figure 1a, 1b, 1c). An emergent exploratory laparotomy was performed with wedge resection of the fundus. During the procedure, copious amounts of purulent material was noted which was cultured, revealing Candida glabrata. Postoperatively, the patient was transferred to the intensive care unit for further management. He remained hypotensive despite fluid resuscitation requiring vasopressors. Patient was started on fluconazole and piperacillin-tazobactam as antimicrobial therapy. His condition improved and was successfully extubated, and transferred to the surgical floors. He was later discharged to a nursing facility in stable condition. DISCUSSION: EG often presents with systemic compromise. The diagnosis requires a CT scan. Although a serious illness, conservative management is usually first attempted before considering surgical intervention. Vasopressors and fluid resuscitation are sometimes required to stabilize the patient hemodynamically. Appropriate antimicrobial therapy should be initiated with coverage of anaerobic organisms, gram negative organisms as well as candida species. If patients develop complications, such as peritonitis or fail conservative management, surgical intervention is warranted. Although rare, ED personnel should consider this condition in differentials of acute abdomen as prompt diagnosis and management can be lifesaving.Table 1.: Illustrating laboratory values on presentationFigure 1.: Figure 1a (coronal), 1b (sagittal) and 1c (axial): abdominal CT scan illustrating pneumatosis seen within the fundal portions and posterior wall of the body of the stomach (red arrows) with gastric distention.