Extraluminal Air Research Articles

Surgical management in acute diverticulitis and its association with multi-detector CT, modified Hinchey classification, and clinical parameters.

To assess whether CT findings, clinical parameters, and modified Hinchey classification are predictive of management outcomes of patients with acute diverticulitis. Data were accrued between January 2014 and December 2015. A total of 301 adult subjects were identified from radiology reports, of which six who did not met the inclusion criteria were excluded, thus yielding 295 subjects. Subjects were 43.1% (n=127) male and 56.9% female (n=168), with mean age 51.9years (range18-90). Two independent abdominal radiologists reviewed all scans; imaging features and a modified Hinchey classification were scored. Descriptive statistics compared the relationships between imaging findings, clinical parametersobtained from medical record review, and modified Hinchey classification with management outcomes. CT findings associated with surgical management include the presence of a pericolonic fluid collection (36.8% vs. 8.2%, P=0.0001), colonic fistula (13.2% vs. 0.4%, P=0.0002), extraluminal air (26.4% vs. 9.3%, P=0.0052), bowel obstruction (5.2% vs. 0.0%, P=0.0162), and a modified Hinchey score of Ib or higher (55.3% vs. 11.7%, P=0.0001). Slightly lower systolic blood pressure was also associated with operative management (137.2mmHg vs. 128.2mmHg, P=0.0220). Specific CT imaging features and modified Hinchey classification are associated with subsequent surgical management in patients with acute diverticulitis.

Systematic Review and Meta-Analysis of CT Features for Differentiating Complicated and Uncomplicated Appendicitis.

Purpose To perform a systematic review and meta-analysis to identify computed tomographic (CT) features for differentiating complicated appendicitis in patients suspected of having appendicitis and to summarize their diagnostic accuracy. Materials and Methods Studies on diagnostic accuracy of CT features for differentiating complicated appendicitis (perforated or gangrenous appendicitis) in patients suspected of having appendicitis were searched in Ovid-MEDLINE, EMBASE, and the Cochrane Library. Overlapping descriptors used in different studies to denote the same image finding were subsumed under a single CT feature. Pooled diagnostic accuracy of the CT features was calculated by using a bivariate random effects model. CT features with pooled diagnostic odds ratios with 95% confidence intervals not including 1 were considered as informative. Results Twenty-three studies were included, and 184 overlapping descriptors for various CT findings were subsumed under 14 features. Of these, 10 features were informative for complicated appendicitis. There was a general tendency for these features to show relatively high specificity but low sensitivity. Extraluminal appendicolith, abscess, appendiceal wall enhancement defect, extraluminal air, ileus, periappendiceal fluid collection, ascites, intraluminal air, and intraluminal appendicolith showed pooled specificity greater than 70% (range, 74%-100%), but sensitivity was limited (range, 14%-59%). Periappendiceal fat stranding was the only feature that showed high sensitivity (94%; 95% confidence interval: 86%, 98%) but low specificity (40%; 95% confidence interval, 23%, 60%). Conclusion Ten informative CT features for differentiating complicated appendicitis were identified in this study, nine of which showed high specificity, but low sensitivity. © RSNA, 2017 Online supplemental material is available for this article.

Predictive factors on CT imaging for progression of uncomplicated into complicated acute diverticulitis

PurposeSince outpatient treatment and omitting antibiotics for uncomplicated acute colonic diverticulitis have been proven to be safe in the majority of patients, selection of patients that may not be suited for this treatment strategy becomes an important topic. The aim of this study is to identify computed tomography (CT) imaging predictors for a complicated disease course of initially uncomplicated acute diverticulitis.MethodsCT imaging from a randomized controlled trial (DIABOLO study) of an observational vs. antibiotic treatment strategy of first-episode uncomplicated acute diverticulitis patients was re-evaluated. For each patient that developed complicated diverticulitis within 90 days after randomization, two patients with an uncomplicated disease course were randomly selected. Two abdominal radiologists, blinded for outcomes, independently re-evaluated all CTs.ResultsOf the 528 patients in the DIABOLO trial, 16 patients developed complications (abscess > 5 cm, perforation, bowel obstruction) within 90 days after randomization. In the group with a complicated course of initially uncomplicated diverticulitis, more patients with fluid collections (25 vs. 0%; p = 0.009) and a longer inflamed colon segment (86 ± 26 mm vs. 65 ± 21 mm; p = 0.007) were observed compared to an uncomplicated course of disease. Pericolic extraluminal air was no predictive factor.ConclusionFluid collections and to a lesser extent the length of the inflamed colon segment may serve as predictive factors on initial CT for a complicated disease course in patients with uncomplicated acute colonic diverticulitis. These findings may aid in the selection of patients not suitable for outpatient treatment and treatment without antibiotics.

Laparoscopic approaches to complicated diverticulitis.

The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis. The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis. New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.

Nonoperative management of perforated acute diverticulitis with extraluminal air: results and risk factors of failure.

The aim of this study was to analyze the results of nonoperative management of patients with perforated acute diverticulitis with extraluminal air and to identify risk factors that may lead to failure and necessity of surgery. Methods included observational retrospective cohort study of patients between 2010 and 2015 with diagnosis of diverticulitis with extraluminal air and with nonoperative management initial. Patient demographics, clinical, and analytical data were collected, as were data related with computed tomography. Univariate and multivariate analyses with Wald forward stepwise logistic regression were performed to analyze results and to identify risk factors potentially responsible of failure of nonoperative management. Nonoperative management was established in 83.12% of patients diagnosed with perforated diverticulitis (64 of 77) with an overall success rate of 84.37%, a mean hospital stay of 11.98±7.44days and only one mortality (1.6%). Patients with pericolic air presented a greater chance of success (90.2%) than patients with distant air (61.5%). American Society of Anesthesiologists (ASA) grade III-IV (OR, 5.49; 95% CI, 1.04-29.07) and the distant location of air (OR, 4.81; 95% CI, 1.03-22.38) were the only two factors identified in the multivariate analysis as risk factors for a poor nonoperative treatment outcome. Overall recurrence after conservative approach was 20.4%; however, recurrence rate of patients with distant air was twice than that of patients with pericolic air (37.5 vs 17.39%). Only 14.8% of successfully treated patients required surgery after the first episode. Nonoperative management of perforated diverticulitis is safe and efficient. Special follow-up must be assumed in patients ASA III-IV and with distant air in CT.

Diverticulitis Diagnosed in the Emergency Room: Is It Safe to Discharge Home?

Inpatient treatment of patients with colon diverticulitis represents a significant financial and clinical burden to the health care system and patients. The aim of this study was to compare patients with diverticulitis in the emergency department (ED), who were discharged to home vs admitted to the hospital. We reviewed all patients evaluated in the ED of a metropolitan health system, with the primary diagnosis of diverticulitis (ICD-9 562.11), from 2010 through 2012. Only patients diagnosed with CT and those with follow-up were included. We identified 240 patients; 132 (55%) were women and mean age was 59.1 years (SD 16.1 years). Imaging findings included extraluminal air (21%), pericolic or pelvic abscess (12%), free fluid (16%), and pneumoperitoneum (6%). One hundred forty-four (60%) were admitted to the hospital and 96 (40%) were discharged to home on oral antibiotics. Patients admitted to the hospital were more likely to be older than 65 years (p= 0.0007), have a Charlson comorbidity score ≥ 2 (p= 0.0025), to be on steroids or immunosuppression (p= 0.0019), and have extraluminal air (p < 0.0001) or diverticular abscess (p < 0.0001) on imaging. Median follow-up for all patients was 36.5 months (interquartile range 25.2 to 43 months). Among patients discharged from the ED, 12.5% returned to the ED or were readmitted within 30 days, with only 1 patient (1%) requiring emergency surgery, but not until 20 months later. Patients admitted to the hospital had similar rates of readmission (15%; p= 0.65). Patients diagnosed with uncomplicated diverticulitis in the emergency room can be safely discharged home on oral antibiotics, as long as CT findings are included in the decision-making process. Patients with complicated diverticulitis on CT scan should be admitted to the hospital with surgical consultation.

Quantitative analysis of patients with celiac disease by video capsule endoscopy: A deep learning method

Background. Celiac disease is one of the most common diseases in the world. Capsule endoscopy is an alternative way to visualize the entire small intestine without invasiveness to the patient. It is useful to characterize celiac disease, but hours are need to manually analyze the retrospective data of a single patient. Computer-aided quantitative analysis by a deep learning method helps in alleviating the workload during analysis of the retrospective videos.Method. Capsule endoscopy clips from 6 celiac disease patients and 5 controls were preprocessed for training. The frames with a large field of opaque extraluminal fluid or air bubbles were removed automatically by using a pre-selection algorithm. Then the frames were cropped and the intensity was corrected prior to frame rotation in the proposed new method. The GoogLeNet is trained with these frames. Then, the clips of capsule endoscopy from 5 additional celiac disease patients and 5 additional control patients are used for testing. The trained GoogLeNet was able to distinguish the frames from capsule endoscopy clips of celiac disease patients vs controls. Quantitative measurement with evaluation of the confidence was developed to assess the severity level of pathology in the subjects.Results. Relying on the evaluation confidence, the GoogLeNet achieved 100% sensitivity and specificity for the testing set. The t-test confirmed the evaluation confidence is significant to distinguish celiac disease patients from controls. Furthermore, it is found that the evaluation confidence may also relate to the severity level of small bowel mucosal lesions.Conclusions. A deep convolutional neural network was established for quantitative measurement of the existence and degree of pathology throughout the small intestine, which may improve computer-aided clinical techniques to assess mucosal atrophy and other etiologies in real-time with videocapsule endoscopy.

Gastric blunt traumatic injuries: A computed tomography grading classification.

AIMTo produce a radiological grading of gastric traumatic injuries.METHODSIn our study, we retrospectively analyzed 32 cases of blunt gastric traumatic injuries and compared computed tomography (CT) data with patients’ surgical or medical development. In all cases, a basal phase was acquired, and an intravenous contrast material was administered via an antecubital venous catheter with acquisition in the venous phase (70-90 s). In addition, a further set of delayed scans was performed 4-5 min after the first scanning session, without supplementary intravenous contrast material, to identify or better define areas of active bleeding. All CT examinations were retrospectively reviewed by two radiologists, with more than 5 years of experience in emergency radiology, to detect signs of gastric injuries and/or associated abdominal lesions according to literature data. Specific CT findings for gastric rupture include luminal content extravasation and discontinuity of the gastric wall, while CT findings suggestive of injury consisted of free peritoneal fluid, extraluminal air, pneumatosis, and thickening and hematoma of gastric wall.RESULTSWe found 32 gastric traumatic injuries. In 22 patients (68.8%), the diagnosis was based on the surgical findings; in the other 10 patients (31.2%), the diagnosis was based on the clinical and CT radiological data. We observed discontinuity of the gastric wall and luminal content extravasation in 1 patient (3.1%); in 10 patients (31.2%), there was extra-luminal air in the peritoneum. In 28 patients (87.5%), there was peritoneal fluid, which was blood in 14 patients (hematoma in 11 patients and contrast material extravasation from active bleeding in 3 patients). In 15 patients (46.9%), there was gastric wall thickening. In 3 patients, it was possible to identify a prevalent involvement of the external layer of the gastric wall, whereas, in 2 patients, the inner side of the gastric wall presented with major involvement. In 3 patients (9.4%), pneumatosis of the gastric wall was detected. In 19 (59.4%) patients, the stomach was full. The fundus was the most frequently damaged part of the stomach because it was involved in 17 patients (53.1%). Based on the observed data, we identified four grades of gastric lesions.CONCLUSIONA radiologic score is helpful for guiding the diagnosis and management (surgical or conservative) of gastric blunt traumatic injuries and stratify patients according to short-term outcomes.

Invasive Moderately-Differentiated Mucinous Adenocarcinoma Incidentally Identified in Perforated Acute Diverticulitis With Abscess Formation

Colonic adenocarcinoma rarely arises within a diverticulum. As illustrated in this case report, such an occurrence presents difficulties in diagnosis, posed by the overlap of radiological findings in diverticulitis and adenocarcinoma and the potential absence of luminal lesion. Here we present a 77-year-old male with acute left lower abdominal pain, fever and leukocytosis. Computarized tomography (CT) imaging revealed extensive colonic diverticulosis, with sigmoid colon wall thickening, extraluminal air and a pericolic abscess. No enlarged lymph nodes were detected. The clinical diagnosis was acute sigmoid diverticulitis with micro-perforation and abscess formation. Partial sigmoidectomy was performed and diverticulitis confirmed; no tumor was identified in the resected colon. However, fragments of mucinous adenocarcinoma were incidentally recognized in the pericolic abscess contents. Immunohistochemical (IHC) studies supported a primary colonic adenocarcinoma, warranting further clinical workup. A subsequent distal sigmoidectomy revealed moderately-differentiated mucinous adenocarcinoma invading through the visceral peritoneum, and arising in a low-grade mucinous neoplasm within a diverticulum. The case illustrates that in a patient with diverticulitis and no evidence of a luminal neoplasm, the unexpected finding of adenocarcinoma in the resected bowel may be attributable to adenocarcinoma arising within a diverticulum.

The role of 256-slice CT in differentiation between non-perforated and perforated appendicitis

ObjectiveThe objective of the present study was to analyze the efficacy of 256-slice CT in differentiation between the perforated and non-perforated appendicitis. Subjects and methodsThe study included 85 patients with acute appendicitis. Appendicectomy and pathological confirmation were done for 79 patients and classified into 44 patients with non-perforated appendix and other 35 patients with perforated appendix. The statistical analysis was performed using six CT findings (abscess formation, phlegmon, extraluminal air, extraluminal appendicolith, focal defect in the appendicular wall and inflammatory changes of the retroperitoneal space) individually and when combined together in five groups. ResultsThe sensitivity, specificity and accuracy of each CT finding were ranged between 20%–51%, 86–100% and 65–76% respectively. The PPV and NPV of these findings ranged between 75–100% and 61–70% respectively. Detection of any of these findings in combination of different groups resulted in raising of the sensitivity reaching between 71 and 97%. ConclusionMultislice CT is considered the modality of choice for imaging of acute appendicitis, not only to confirm the diagnosis but also it plays an important role in assessment of appendicular complication, particularly in detection of perforated appendix.

Clinical Analysis of Stercoral Perforation without Mortality

Aims: This study was designed to review the clinical features of stercoral colonic perforation and to evaluate the appropriate intraoperative procedures and postoperative management to achieve the best surgical outcomes. Methods: Between January 2009 and December 2015, 12 patients with stercoral perforation confirmed surgically and pathologically were included in this study, and their medical records were reviewed retrospectively. Results: The enrolled patients included 2 men and 10 women; their mean age was 73.8 years. Abdomino-pelvic CT was an important diagnostic tool, which revealed fecalomas, extraluminal air and pericolic fat stranding in all patients. Hartmann's operation was performed in all patients, with a mean operation time of 239.3 min. Perforation site was in the left colon, mainly in the sigmoid colon. Intraoperative hypotension developed in 8 cases (66.7%). Postoperatively, all patients needed intensive care for 6.5 days and 6 patients needed the administration of inotropic agents for 3.0 days postoperatively. Disseminated intravascular coagulation developed in 10 cases (83.3%). There was no surgical mortality. Conclusion: Colorectal surgeons should be aware of the possibility of stercoral perforation, despite its rare incidence. Deep understanding of this potentially fatal disease by surgeons could reduce surgical mortality and improve postoperative outcomes.

Acute Perforating Diverticulitis Associated with Active Ulcerative Colitis: Yes, It Does Occur

A 79-year-old female with a past medical history of UC presented with persistent watery diarrhea, abdominal pain, nausea, vomiting, and low-grade fever. She had originally presented 1.5 years prior with persistent hematochezia prompting colonoscopy which revealed congestion, erosions, erythema, friability, granularity and loss of vascularity extending in a continuous and circumferential pattern from the anus to the sigmoid colon. Numerous small and large-mouthed diverticula were found in the sigmoid colon and in the descending colon. Rectosigmoid biopsy revealed crypt distortion with increased lymphoplasmacytic and neutrophilic inflammatory infiltrate in the lamina propria and associated cryptitis, crypt abscesses, and reactive epithelial cell changes consistent with a diagnosis of UC. Over the next 1.5 years she intermittently tolerated combinations of 5-aminosalicylic acid preparations (5-ASA) and steroid suppositories and enemas with concomitant oral 5-ASA therapies. However she eventually developed steroid-dependent UC. Given persistent side effects of chronic steroid therapy biologic therapy with infliximab was started approximately one week prior to presentation. On admission to hospital, she was started on broad-spectrum antibiotics and intravenous steroids. With a negative infectious workup, she was continued on an accelerated infliximab program. This was complicated by the development of Clostridium Difficile colitis, requiring oral vancomycin therapy. She subsequently developed worsening abdominal pain prompting computed-tomography evaluation which revealed colitis with increased wall thickening and pericolonic inflammation along the descending colon with an associated droplet of extraluminal air and rim-enhancing fluid in the left paracolic gutter compatible with perforation. She underwent emergent exploratory laparotomy with identification of a descending colonic perforation resulting in subtotal colectomy with end ileostomy. Her post-op course was complicated by multiple pelvic fluid collections documented on serial imaging requiring drainage and growth of Vancomycin-Resistant Enteroccocus. Microscopic surgical pathology showed chronic UC associated with extensive colonic diverticulosis with acute perforative diverticulitis, subserosal abscesses and acute purulent serositis. The inflammation of UC was limited to the deep submucosa. There was no dysplasia, granulomata, or viral inclusions present.

Diverticulitis: does age matter?

Acute diverticulitis has been traditionally associated with worse outcome in young patients, indicating a more aggressive surgical approach is required for them. The aim of this study was to assess whether acute diverticulitis was more virulent in young patients. A retrospective, cross-sectional study included all patients who were admitted for a first episode of acute diverticulitis between January 2004 and December 2013. The patients were divided into two groups (≤50 years and >50 years) based on their age. Patients' characteristics, clinical and surgical data were recorded and analyzed. Overall, 636 patients were included in the database, including 177 (27.8%) in the younger group and 459 in the elder group. There were no significant differences between the groups in disease complexity, peritonitis, laboratory work-up, vital signs on presentation, bowel obstruction or the presence of fistula and abscess in need of drainage. Younger patients had more free extra-luminal air on computed tomography (CT) scan (P = 0.03). Surgical data, including the intra-operative modified Hinchey score and the need for emergency and additional surgery did not significantly differ between the two groups. Young patients had more readmissions (P = 0.01) due to acute diverticulitis, diverticular complications and elective surgery. Length of hospital stay (P = 0.0001) was longer and postoperative complications were more common in the elder patients. The clinical presentation of acute diverticulitis does not seem to be worse in the young population. Younger patients tend to have a more severe presentation on CT scan and more readmissions, but this did not translate to a more severe disease course.

CT findings of post-polypectomy coagulation syndrome and colonic perforation in patients who underwent colonoscopic polypectomy

To investigate the clinical characteristics and computed tomography (CT) findings of post-polypectomy coagulation syndrome (PPCS) and colonic perforation in patients who have undergone colonoscopic polypectomy. Through a hospital database search, 5542 adult patients (age >40 years) who had undergone colonoscopic polypectomy from January 2011 to November 2014 were identified. After identification of patients with PPCS and colonic perforation, two abdominal radiologists reviewed the CT images of the patients in consensus. Eight patients (0.14%) with PPCS and six patients (0.11%) with perforation were identified. Five patients were excluded for absence of CT examination, leaving four patients with PPCS and five patients with perforation included in the study. Three of the patients with perforation eventually underwent surgery, while all the patients with PPCS completely recovered with conservative management. On CT images, the involved colonic wall was longer and thicker in the PPCS group than in the perforation group. All four patients with PPCS showed a mural defect filled with fluid and stratified enhancement with surrounding infiltration. Two patients, who did not undergo surgery for perforation, did not show surrounding infiltration and fluid collection. On CT images, PPCS shows severe mural thickening with a stratified enhancement pattern, a mural defect filled with fluid and surrounding infiltration in addition to absence of extraluminal air. In patients with perforation, absence of CT findings suggestive of surrounding inflammation or peritonitis would help in choosing non-surgical management.

Tracheal Diverticula

Extraluminal paratracheal air bubbles are occasionally seen on computed tomography (CT) studies that include the thoracic inlet (ie, CT of the neck, of the cervical spine, and of the chest). In most cases, these paratracheal air bubbles are tracheal diverticula (TD), sometimes also referred to as tracheal pouch, tracheocele, and tracheogenic cyst. TD are most commonly seen at the right posterolateral aspect of the upper trachea at the level T1-T3. Because of their typical location and appearance, they are easily recognized and should not be confused with pneumomediastinum or other causes of air bubbles in the same region. This article describes the prevalence, possible pathophysiology, and associated complications of TD and illustrates the spectrum of their appearance on CT.

Pneumothorax, pneumomediastinum, pneumoperitoneum and extensive subcutaneous emphysema resulting from endoscopic mucosal resection secondary to colonoscopy: A case report.

Rectal perforation is an unusual complication of therapeutic colonoscopy. The present study reports the case of a patient with a rare manifestation of pneumothorax, pneumomediastinum, pneumoperitoneum and extensive subcutaneous emphysema that resulted from an endoscopic mucosal resection following a colonoscopy of the rectum. Only 3 cases of colonic perforation and 1 case of rectal perforation have been described previously, of which the clinical diagnoses and treatments were varied, and no results of follow-up studies were reported. In the present study, dyspnea and neck swelling were acute signs of extraluminal air that resulted from rectal perforation. Computed axial tomography was an effective diagnosis method, and is recommended for the early recognition of colorectal perforation. Appropriate management and a close follow-up are crucial for optimal results.

Small Bowel Perforations: What the Radiologist Needs to Know

The incidence of small bowel perforation is low but can develop from a variety of causes including Crohn disease, ischemic or bacterial enteritis, diverticulitis, bowel obstruction, volvulus, intussusception, trauma, and ingested foreign bodies. In contrast to gastroduodenal perforation, the amount of extraluminal air in small bowel perforation is small or absent in most cases. This article will illustrate the main aspects of small bowel perforation, focusing on anatomical reasons of radiological findings and in the evaluation of the site of perforation using plain film, ultrasound, and multidetector computed tomography equipments. In particular, the authors highlight the anatomic key notes and the different direct and indirect imaging signs of small bowel perforation.

Acute Perforated Diverticulitis: Assessment With Multidetector Computed Tomography

Colonic diverticulitis is a common condition in the western population. Complicated diverticulitis is defined as the presence of extraluminal air or abscess, peritonitis, colon occlusion, or fistulas. Multidetector row computed tomography (MDCT) is the modality of choice for the diagnosis and the staging of diverticulitis and its complications, which enables performing an accurate differential diagnosis and addressing the patients to a correct management. MDCT is accurate in diagnosing the site of perforation in approximately 85% of cases, by the detection of direct signs (focal bowel wall discontinuity, extraluminal gas, and extraluminal enteric contrast) and indirect signs, which are represented by segmental bowel wall thickening, abnormal bowel wall enhancement, perivisceral fat stranding of fluid, and abscess. MDCT is accurate in the differentiation from complicated colon diverticulitis and colon cancer, often with a similar imaging. The computed tomography-guided classification is recommended to discriminate patients with mild diverticulitis, generally treated with antibiotics, from those with severe diverticulitis with a large abscess, which may be drained with a percutaneous approach.

Emphysematous Gastritis: A More Recognized Complication in Diabetic Patients

Emphysematous gastritis is a condition involving invasion of the gastric wall by gas-producing organisms. Previous relevant articles include case reports and a case review of 41 patients. Computed Tomography (CT) findings reveal a streaky and linear band of air with thickening of gastric wall in the setting of poorly controlled diabetes. Mortality can be as high as 62%, and early recognition with prompt delivery of broad-spectrum antibiotics is key in management. 24 year old white female presents with multiple admissions for abdominal pain. Medical history includes uncontrolled diabetes type 1, hypothyroidism, kidney disease, and prior peptic ulcer. CT Abdomen reveals extraluminal free intraperitoneal air in the left upper abdomen concerning for perforated ulcer. An EGD is performed, revealing an erythematous patch along the greater curvature. Biopsies show chronic inactive gastritis with mucosal hemorrhage without H. pylori. After 4 additional admissions within 60 days, a repeat CT Abdomen for abdominal pain reveals air in an edematous gastric wall with extensive intrahepatic portal venous gas. Meropenem is added, but there is persistence of abdominal pain and poor oral intake 18 days into admission. Repeat CT shows distended gastric lumen without wall thickening or definite pneumatosis. Repeat EGD shows a non-bleeding, 7x2cm necrotic ulcer in lesser curvature of stomach. Patient was taken to surgery for Roux-en-Y. Current knowledge of emphysematous gastritis is limited to case reports, with only one published textbook found. Predisposing factors include: diabetes, malignancy, alcohol, NSAID use, post-abdominal or pelvic surgery, and corrosive ingestion. Subsequent ischemia or necrosis permits gas-forming organisms to enter the gastric wall. CT findings include air presenting as streaky and linear consistency, which can be differentiated from gastric emphysema as the latter presents with round air bubbles. Management is geared by early recognition, broad spectrum antibiotics, and supportive care. Consider surgery when there is gastric perforation, or uncontrolled sepsis. The overall mortality is as high as 62%, and it is associated with gas-producing bacteria and fungi Emphysematous gastritis is a rare, but deadly complication in poorly controlled diabetic patients. Consider this condition when there is gastric thickening, linear or streaky air in wall on CT imaging. Management includes broad spectrum antibiotic and supportive care.

An Interesting Case of Gastric Pneumatosis Masking Acute Appendicitis

Gastric pneumatosis, which is defined as the finding of gas within the gastric wall, is one of the least common presentations seen in the spectrum of pneumatosis intestinalis (finding of gas within the gastrointestinal tract). In the majority of these cases, bowel ischemia or necrosis such as necrotizing enterocolitis, volvulus, or ischemic bowel disease has been identified as the cause. To our knowledge, only a few cases of pneumatosis intestinalis secondary to acute appendicitis have been reported in the literature. We present the case of a 66-year-old woman with history of gastro-esophageal reflux disease who presented with two week history of constant chest pain associated with severe epigastric pain radiating to the back. Her abdominal pain was alleviated by proton pump inhibitors and antacids that she received in the Emergency Room. A complete cardiac work up was found to be unremarkable. Subsequent work up also included an abdominal computed tomography angiography (CTA) to rule out an aortic dissection, which revealed gastric fundus intramural gas without evidence of extraluminal or portovenous air. The appendix was not visualized in this study. Initial differential diagnoses of gastric pneumatosis in this patient included acute pancreatitis, peptic ulcer disease, gall bladder disease. The following day, the patient became febrile with a new leukocytosis (WBC count of 16,000) and complained of epigastric pain migrating to her right lower abdomen. Abdominal computed tomography (CT) with contrast was then obtained and conclusively confirmed the presence of a dilated appendix measuring 1.4 cm, along with significant diffuse adjacent inflammatory changes. She then underwent emergent laparoscopy with excision of a ruptured appendix. Fortunately, subsequent esophagogastroduodenoscopy did not reveal any evidence of bowel ischemia or infarction. The patient recovered well following the surgery and made a full recovery. This case suggests that the presence of gastic pneumatosis may not always be an ominous sign that indicates bowel infarction. This finding in the context of an atypical presentation should not delay the diagnosis of acute appendicitis. As the finding of pneumatosis intestinalis may be innocuous or indicate the presence of a life-threatening abdominal catastrophe, it is therefore important to make this crucial distinction through the interpretation of clinical information obtained from a thorough history, physical examination, laboratory and radiographic data.Figure 1