S3063 Air on the Side of Caution: A Case of Gastric Emphysema

Abstract

INTRODUCTION: Gastric pneumatosis, the presence of intramural gas in the stomach, is a rare but alarming radiographic finding. Gastric emphysema (GE) and emphysematous gastritis remain the two most important differential diagnoses of gastric pneumatosis, both differing vastly in their management and prognosis. Due to these differences, it is essential to reach an accurate clinical diagnosis early. Here we describe the case of a young male with GE due to severe gastroparesis from uncontrolled diabetes. CASE DESCRIPTION/METHODS: A 36 year-old COVID-19 positive male with a history of uncontrolled Type 1 Diabetes, Hepatitis C, and Hirschsprung disease presented with generalized weakness, fatigue, polyuria, and polydipsia for two days. Laboratory work revealed diabetic ketoacidosis which improved with intravenous (IV) fluids and insulin. However, his course was complicated by persistent nausea, inability to tolerate oral diet, abdominal distension, and worsening leukocytosis. Computed Tomography (CT) of the abdomen demonstrated a markedly distended stomach containing air and undigested food, air in the gastric wall, gas and thrombus in the left portal vein, and pancolitis. He remained afebrile, hemodynamically stable with negative blood cultures and was initially treated conservatively with fluconazole and piperacillin-tazobactam, nasogastric suction and supportive care. Repeat CT of the abdomen two days later showed improvement in gastric pneumatosis and portal venous gas. Subsequent EGD revealed retained gastric contents, an open pylorus, and large necrotic-appearing ulcerations extending most of the lesser curvature and fundus of the stomach. These findings were consistent with GE, likely a chronic issue from longstanding gastroparesis. However microvascular thrombi related to COVID remain on the differential as there is a known propensity for a procoagulable state in these patients. DISCUSSION: GE can be due to an increase in intraluminal pressure or mucosal injury that leads to intramural gas formation. In our patient, we suspect his GE was due to uncontrolled diabetes, causing severe gastroparesis and gastric wall distention. GE is benign and managed with observation and conservative treatment. Comparatively emphysematous gastritis is often associated with systemic toxicity, is potentially fatal, and often requires more aggressive therapy including surgery. As in the majority of GE cases, our patient's symptoms improved with conservative treatment and follow-up imaging revealed interval improvement.Figure 1.: CT of the abdomen demonstrated a markedly distended stomach containing air and undigested food as well as air in the gastric wall (demarcated by blue arrows).Figure 2.: Repeat CT of the abdomen demonstrating improvement in gastric pneumatosis and portal venous gas.Figure 3.: EGD demonstrating an open pylorus and large necrotic-appearing ulcerations extending most of the lesser curvature and fundus of the stomach.