Successful Medical Management of Gastric Pneumatosis with Associated Portal Venous Air

Abstract

Purpose: An 80-year-old woman with afib, DM, COPD, and cardiomyopathy was admitted with dyspnea and bilateral pneumonia. She was treated with meropenem IV, and a few days later, she began to complain of epigastric pain and nausea. The gastrointestinal symptoms progressed, and a CT scan revealed scant air in the main portal vein (Figure 1), gastric pneumatosis (Figure 2) and mild gastric distention. GI and surgical consultations were requested. Abdominal exam showed mild epigastric tenderness without signs of peritoneal irritation. Blood work revealed a normal peripheral WBC and a normal serum bicarbonate level. She was kept NPO, metronidazole and esomeprazole IV were added to her medical regimen and ngt suction was instituted. The patient remained clinically stable, her abdominal pain and nausea subsided and a repeat CT scan 48 hours later revealed resolution of the gastric pneumatosis and PV air. NGT suction was then discontinued and an oral diet was allowed. H. pylori stool antigen test was negative. The patient made a full clinical recovery and was discharged 2 weeks later. Outpatient EGD, performed 10 weeks later, revealed mucosal scarring in the gastric antrum.Figure: Axial CT demonstrating air in portal vein (circle).Figure: Axial CT demonstrating gastric pneumatosis (circle).Conclusion: Symptomatic gastric pneumatosis with PVG usually presages the need for surgical intervention. This case suggests that under the proper clinical scenario, with a thoughtful multidisciplinary approach, experienced clinicians may successfully manage this problem non-operatively, and there is not always a mandate for surgical intervention.