What Is the Role of Upper Endoscopy in Patients With Gastric Pneumatosis?

Abstract

Gastric pneumatosis is a rare finding. It can be seen with both gastric emphysema and emphysematous gastritis. Both may have similar presentations and differentiating between the two conditions is difficult radiographically. However, making the distinction between them is crucial; as GE has a benign clinical course while EG is more maleficent, and carries significant mortality. Early endoscopy may help differentiate between the two processes. We present a series of two immunocompromised patients that presented with radiographic findings consistent with gastric pneumatosis. A 52 y.o male with history of HIV, diabetes, and dialysis dependent end-stage renal disease presented with a 3-day history of epigastric fullness, vomiting, and chills. He was febrile at 101.6F and his abdominal exam revealed mild distension, active bowel sounds with no appreciable tenderness. CT abdomen revealed a distended stomach with air within the gastric wall as well as the presence of portal venous gas. Endoscopy was performed on the 2nd day of hospitalization and showed erythematous gastric mucosa in the body and antrum. He improved with conservative measures including antibiotics and was eventually discharged. The second case was a 58 y.o female with history of stage 4 squamous cell lung carcinoma with bony metastases, ESRD on dialysis, systolic heart failure, and diabetes who presented with left hip pain and found to have left proximal femur erosion with effusion and was admitted for hemiarthroplasty. On POD #1 she became unstable and was transferred to the MICU. A CT abdomen revealed portal venous gas with pneumatosis of the stomach and adjacent duodenum. Endoscopy performed the same night revealed a diffusely ulcerated, edematous hemorrhagic gastric mucosa sparing the pre-pyloric region. The patient was a poor surgical candidate and was subsequently managed medically. Despite resuscitative efforts the patient experienced cardiac arrest and expired. Treatment for GE is supportive as this condition tends to be self limiting. Management of EG is more active including correction of acid-base and electrolyte abnormalities, fluid resuscitation and IV antibiotics. Gastrectomy may be necessary in EG if medical management fails. As both conditions can present similarly differentiating between the two is pivotal. We found early endoscopy helped guide our management. We recommend consideration of endoscopy as part of the evaluation of patients presenting with gastric pneumatosis.2622_A Figure 1. Coronal CT image showing portal venous gas with pneumatosis of the stomach and the adjacent duodenum2622_B Figure 2. Transverse CT image showing portal venous gas with pneumatosis of the stomach and the adjacent duodenum