Gastric Pneumatosis Research Articles

Gastric pneumatosis and concurrent aeroportia due to gastric outlet obstruction: A case report.

Introduction and importanceGastric pneumatosis with concurrent hepatic portal vein gas is an extremely rare condition in the adult population. It can be idiopathic or associated with well-known etiologies. Gastric outlet obstruction can progressively inflate the stomach and cause pneumatosis. Regarding abdominal signs and the presence of acute abdomen, management varies from just conservative to emergent surgical interventions.Case presentationWe introduce an adult patient who presented to our hospital with weakness and dyspnea. After initial measures, unexpectedly we found intraabdominal free gas, concurrent gastric pneumatosis, and aeroportia. Due to the absence of positive abdominal signs, the patient was treated successfully without any surgical or endoscopic interventions.DiscussionGastric outlet obstruction is a well-known cause of gastric pneumatosis. Progressive dilation of the stomach due to pyloric stenosis is well-described both in infants and adult populations.ConclusionIn stable patients, gastric drainage and correction of electrolyte disturbance are the only required treatment. However endoscopic and surgical interventions should be considered in unstable patients or those developing acute abdomen.

Case report: gastric ischemia, a fatal disease of gastric pneumatosis

BackgroundGastric pneumatosis indicates the presence of air within the stomach wall. The etiologies included gastric ischemia, gastric intramural infection, gastric mucosal disruption, and secondary to pneumomediastinum. Gastric ischemia is rare because of the rich collateral blood supply to the stomach.Case presentationAn 82-year-old man presented to the emergency department with a 2-day history of epigastric fullness, following by fever and low blood pressure. Chest X-ray and abdominal computed tomography revealed gastric pneumatosis at the gastric fundus. The esophagogastroduodenoscopy confirmed the ischemic change of mucosa at the gastric fundus. After antibiotics and medical management, the patient became better and was eventually discharged.ConclusionFor the diagnosis of gastric ischemia, physicians should be alert to the hints of gastric pneumatosis from X-ray and computed tomography. It is important to distinguish between gastric ischemia and the other causes of gastric pneumatosis to judge clinical management.

Gastric Pneumatosis After Accidental Ingestion of Concentrated Hydrogen Peroxide: A Case Report.

IntroductionHydrogen peroxide is a common oxidizing agent that if ingested may cause injury to the gastrointestinal tract or embolic events. Although therapy is primarily supportive, gastric perforation is a rare but serious complication of corrosive ingestion that may require surgical treatment.Case ReportWe report the case of a 77-year-old male who presented for nausea and vomiting after accidentally ingesting approximately 150 milliliters of 35% hydrogen peroxide. Computed tomography revealed gastric pneumatosis and extensive portal venous air. The patient was admitted for observation with plans for endoscopy; however, due to the limitations of our small community hospital, he was transferred to a tertiary care center due to concern for a potential gastric perforation.ConclusionThe presence of portal venous air as a result of peroxide ingestion may be treated conservatively depending on presenting symptoms; however, severe injury such as gastrointestinal perforation may necessitate surgical intervention.

Non-Operative Management of Emphysematous Gastritis: A Case Report

Gastric pneumatosis, air within the gastric wall, is a rare finding on imaging. Gastric pneumatosis is seen in both benign and life-threatening conditions. Emphysematous gastritis is a rare, and potentially life-threatening, form of gastritis. Early and effective non-operative management with bowel rest, nutritional support, intravenous hydration, and intravenous broad-spectrum antibiotics is a reasonable option for management of emphysematous gastritis. There is still no consensus and strict guidelines in management of emphysematous gastritis, but as this and a handful of other case reports show, immediate surgical intervention may not always be the answer.

Gastric Pneumatosis: An Atypical Presentation of Desmoid Tumor.

Case presentationA middle-aged woman presented to the emergency department with a chief complaint of abdominal pain, fever, vomiting, and diarrhea. Abdominal computed tomography revealed gastric pneumatosis and air in the portal system. The patient had an unfavorable clinical course with pneumoperitoneum and septic shock due to secondary peritonitis. She underwent emergency laparotomy where neoformation of the mesentery root was found with infiltration of the small intestine and jejunal perforation. The anatomopathological study of the tumor revealed that it was a desmoid tumor.DiscussionTo our knowledge this is the first report in the literature of gastric pneumatosis as the initial presentation of a mesenteric desmoid tumor. Although it usually has a benign clinical course, its locally invasive characteristics can lead to critical illness. Physicians shouldn’t overlook these types of complications, as early identification and surgical intervention can modify the prognosis and shorten hospital stay.

Gastric pneumatosis in a patient with anorexia nervosa.

Gastric pneumatosis can be caused by mechanical force, pulmonary disease, bacterial infection, and ischemic condition. It can be managed conservatively, however, according to the etiology, surgery may be required.

Ingestion of food grade hydrogen peroxide with resultant gastrointestinal and neurologic symptoms treated with hyperbaric oxygen therapy: case report and review with emphasis on the therapeutic value of HBO2 in vascular gas embolism

A 52-year-old male accidentally ingested approximately 100 mL of 35% hydrogen peroxide (H2O2), resulting in the sudden onset of gastrointestinal and neurologic symptoms. Non-contrast abdominal CT revealed extensive portal venous gas and gastric pneumatosis. The patient was treated with hyperbaric oxygen therapy which resulted in complete resolution of symptoms. The case highlights the therapeutic value of hyperbaric oxygen therapy in the treatment of vascular gas embolism and mitigation of concentrated H2O2 ingestion toxicity.

Could SARS-CoV-2 be associated with emphysematous gastritis?

A 90-year-old patient was admitted to the emergency department with symptomatology of fever, cough, dyspnea, diarrhea, and abdominal pain. Physical examination revealed fever, tachypnea, hypoxemia, bibasal crackles and diffuse abdominal pain. Nasopharyngeal swabs were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on RT-PCR test. The blood test showed lymphopenia (0.67 × 10³/µL), neutrophilia (7.58 × 10³/µL), lactic acidosis (pH 7.29, lactate 8.7 mmol/L), elevated C-reactive protein (2.50 mg/dL) and procalcitonin (7.32 ng/mL). Chest x-ray revealed bilateral ground-glass opacities that suggested coronavirus disease 2019 (COVID-19) pneumonia. Abdominal CT scan showed diffuse gastric pneumatosis with progression to the esophagus and duodenum (Figs. 1A/B and 2A), associated with hepatic portal venous gas (Fig. 2B). These findings were compatible with COVID-19 pneumonia associated with severe emphysematous gastritis and massive gastric distension. Supportive care and broad-spectrum antibiotic were prescribed. The patient, however, showed respiratory worsening and he died during admission.Fig. 2Contrast-enhanced computed tomography (CT) with sagittal (A) and coronal (B) sections showing hepatic portal venous gas and diffuse gastric pneumatosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Emphysematous gastritis is a severe infection caused by gas-forming bacteria, with a high risk of mortality [[1]Singhania N. Bansal S. Singhania G. et al.Emphysematous gastritis.J Emerg Med. 2020; 59: e259-e261Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. On the other hand, SARS-CoV-2 is associated with several gastrointestinal disorders due to the invasion of the gastrointestinal angiotensin-converting enzyme 2 (ACE2) receiver and hypercoagulability caused by vascular endothelial cell injury. To our knowledge, this is the first published case of emphysematous gastritis in a patient with SARS-CoV-2 infection. Further research is needed to establish this relationship.

Use of indocianine green fluorescence in acute mesenteric ischemia

Introducción: La isquemia mesentérica aguda presenta una elevada morbi-mortalidad y constituye un reto intraoperatorio en el manejo de las áreas isquémicas. En este contexto, analizamos el uso de la fluorescencia con verde de indocianina para valorar la vascularización intestinal a través de 3 casos clínicos. Presentación de los casos: presentamos 3 casos clínicos intervenidos por isquemia mesentérica aguda. Se realiza valoración de la viabilidad intestinal bajo luz infrarroja tras la infusión endovenosa de 25 mg de verde de indocianina. El caso 1 es un varón de 42 años con múltiples antecedentes de enfermedad vascular grave, que presenta una isquemia mesentérica aguda masiva con afecación parchaeada de múltiples segmentos intestinales. La fluorescencia permite la realización de dos resecciones intestinales ajustadas con doble anastomosis intestinal. El caso 2 es una mujer de 74 años con antecedentes de fibrilación auricular no anticoagulada a la que se le decide realizar una cirugía urgente al objetivarse una neumatosis esofágica, gástrica y en sistema porta, como signos indirectos de isquemia, en la TAC urgente. Durante el acto quirúrgico se halla una isquemia de ileon terminal y colon derecho sin claros signos de afectación a nivel esófago-gástrico. La valoración tras administración de ICG discrimina la clara afectación isquémica desde ileon terminal a colon ascendente y parcheada en colon transverso e izquierdo, sin afectación esofágica ni gástrica. El caso 3 es una mujer de 49 años con enfermedad de Takayasu aortoilíaca y visceral y cirugía de revascularización del tronco celíaco. Ante el aumento del dolor abdominal, una nueva TAC evidencia neumatosis colónica. La laparotomía urgente muestra necrosis a nivel del colon izquierdo e hipoperfusión del ciego. La administración de ICG halla una falta de captación de todo el colon. Se realiza una colectomía subtotal con ileostomía y fístula mucosa. Conclusiones: La fluorescencia con ICG aporta una mejor visualización de la vascularización intestinal en la IMA, y permite determinar los límites del tejido afecto para realizar resecciones ajustadas.

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

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.

S3037 Unfortunate Complications of Acute Hemolytic Anemia, Gastric Pneumatosis With Superior Mesenteric Artery Occlusion, and Stroke Observed in a Patient With COVID-19

INTRODUCTION: The coronavirus disease 2019 (COVID-19) has been an ongoing global threat and has required the medical community to be vigilant in finding complications associated with the virus. Our case study highlights severe complications seen in a critically ill patient due to the SARS-COV-2 virus who developed acute hemolytic anemia, gastric pneumatosis with SMA occlusion, and stroke. Further investigation is needed to identify a common pathway that could be causing a variety of these symptoms. CASE DESCRIPTION/METHODS: A 68 year old female with a known PMH of CVA, HTN, HLD, and DM presented to the hospital for evaluation of right-upper quadrant abdominal pain and flank pain. On physical examination, the patient was jaundiced with diffuse abdominal distention. A SARS COV- 2 PCR test was obtained for a patient having non-specific abdominal pain, which came back positive. Her initial lab values on admission presented concerns of hemolysis and the patient was started on prednisone 1mg/kg for cacute hemolytic anemia. On Hospital day 3, her oxygen requirements continued to decline and the patient was placed on remdemsivr therapy. A CT abdomen and pelvis showed a developing gastric pneumatosis within a portion of the dilated small bowel loops with an arterial occlusion involving the first 2.5cm of the superior mesenteric artery. Later that evening, the patient developed a new onset left facial droop and left sided hemiparesis. A stat CT and CT angiogram was negative for any large vessel occlusion. Stat labs depicted a hemoglobin drop to 5 g/dl. The patient received TPA given her new onset of symptoms and was transfused 2 units of packed red blood cells. The next day, a repeat CT scan of the head depicted concerns of LVO note seen on initial read. The patient was placed on comfort care measures as surgery would be futile and her intestines were extensively damaged. DISCUSSION: The SARS-COV-2 virus ability to cause such cytokine release and to have diffuse entry into the cells may be an explanation in diffuse tissue injury. Our case report highlights an important point that the virus can cause asymptomatic patients to progress into a rapid decline of overall health and has the ability to affect multi-organ systems. Further research and treatment options are required with SARS-COV2 to understand the pathophysiology behind the pro-inflammatory response seen in various organ systems due to the virus and treatment options.

S2538 Pneumatosis With Hepatic Portal Venous Gas in COVID-19

INTRODUCTION: Hepatic portal venous gas (HPVG) historically has been known to be an ominous sign in patients with acute abdominal pathology including necrotizing enterocolitis and pneumatosis intestinalis, which prompt urgent surgical intervention as the underlying etiologies carry a mortality of greater than 75%. However, with advancements in diagnostic imaging modalities, recent studies suggest a mortality rate of 25-35% due to increased awareness of benign causes. Here we report a rare presentation of HPVG in the setting of acute COVID-19 infection. CASE DESCRIPTION/METHODS: A 42-year-old male with type 1 diabetes mellitus and end stage renal disease (with pancreatic and renal transplants), presents with a 4-day history of abdominal pain, nausea, nonbloody/nonbilious vomiting, and nonbloody loose stools. Patient was afebrile, tachycardic, and hypotensive (73/41 mmHg) on arrival. Lab work revealed lymphocytopenia with an absolute lymphocyte count of 610 cells/µL, contraction alkalosis with severe electrolyte derangement (Na 123, K 2.1, Cl < 50, HCO3 >45), serum lactate of 6.9 mmol/L, ferritin 4202 ng/mL, CRP 2.51 mg/dL, and D-dimer 230 ng/mL. CT abdomen and pelvis revealed a right middle lobe ground glass opacity suspicious for COVID-19 infection, along with gastric pneumatosis with severe extensive HPVG (image 1 and image 2). COVID-19 PCR nasopharyngeal swab was positive. Rapid viral panel via PCR, stool culture, and Clostridium difficile toxin PCR were negative. The patient received fluids and antibiotics. Laparotomy was deferred to assess for any interval clinical improvement. On hospital day 2, repeat CT abdomen and pelvis revealed gastroenterocolitis with complete resolution of pneumatosis and portal venous gas and no evidence of active GI bleeding (image 3). He was discharged on day 5 with resolution of electrolyte derangements and symptom improvement. DISCUSSION: Although there have been increasing numerous benign causes of HPVG such as following endoscopic procedures, hepatic transplantation, and viral gastroenteritis, not much is known about HPVG in the setting of COVID-19. This case is one of two known cases of COVID-19 induced pneumatosis, and the only known case complicated by transient HPVG. It highlights the importance of gastrointestinal complications of COVID-19, as it is not limited to predominantly respiratory symptoms. It is important to note that both cases of COVID-19 induced pneumatosis were successfully treated with bowel rest, adequate hydration, and intravenous antibiotics.Image 1.: CT imaging depicting extensive hepatic portal venous gas (HPVG).Image 2.: CT imaging depicting gastric pneumatosis (arrows).Image 3.: Complete resolution of HPVG and gastric pneumatosis on repeat CT imaging.

S3033 Percutaneous Endoscopic Gastrostomy (PEG) Tube Dislodgment into the Duodenum Resulting in Intestinal Obstruction, Gastric Pneumatosis, and Portal Venous Gas

S3033 Percutaneous Endoscopic Gastrostomy (PEG) Tube Dislodgment into the Duodenum Resulting in Intestinal Obstruction, Gastric Pneumatosis, and Portal Venous Gas

S3039 Vomiting-Induced Gastric Pneumatosis and Portal Venous Gas

INTRODUCTION: The air in the stomach wall is called gastric pneumatosis, which is caused by gastric emphysema (GE), which is self-resolving, and emphysematous gastritis, which is likely due to infectious etiology and indicates a worse prognosis. We report a case of a vomiting-Induced gastric pneumatosis. CASE DESCRIPTION/METHODS: An 80-year-old male presented to the hospital with complaints of epigastric pain, nausea, and vomiting for the last two days. He had a regular bowel movement and denied any fever, or blood in the stool. His blood work, like WBC, lactate, lipase, and comprehensive metabolic panel, were within normal limits. He had a fluoro esophagram which did not show extraluminal leak in the gastroesophageal junction or proximal stomach (figure: a). CT scan of this abdomen showed pneumatosis of the posterior gastric greater curvature wall with portal venous gas (figure: b). Endoscopy showed mild acute mucosal changes in the proximal stomach (figure: c). He was treated conservatively and discharged home. DISCUSSION: Intestinal pneumatosis is referred to the presence of gas within the wall of the gastrointestinal tract and it can appear in any site from stomach to the rectum. The stomach is the least common site of presentation; one retrospective study identified only 18 cases during a period of 15 years. Emphasizing on the gastric chamber, it can be classified into two categories: emphysematous gastritis and gastric emphysema. GE can be caused by trauma like severe vomiting, or CPR, gastric outlet obstruction, and alveolar rupture. Clinical manifestations in GE are usually nonspecific. These patients are usually asymptomatic or complain of nausea, vomiting, epigastric discomfort, or abdominal pain. In general, it has a benign clinical course and resolves spontaneously resolution after the cause is removed. The presence of gas in the portal venous system can be an acute abdominal emergency, but it is also associated with GE. Vomiting induced GE and portal vein gas has a benign clinical course and resolves spontaneously without any complication.Figure 1.: Fluoro Esophagram did not show extraluminal leak in the gastroesophageal junction or proximal stomach. Unremarkable esophagram.Figure 2.: CT scan of this abdomen showed pneumatosis of the posterior gastric greater curvature wall with portal venous gas.Figure 3.: Endoscopy showed mild acute mucosal changes in the proximal stomach.

S2046 Pseudo Pseudo? Chronic Intestinal Pseudo-Obstruction Presenting as Mechanical Obstruction and Recurring Despite Surgery

INTRODUCTION: Chronic intestinal pseudo-obstruction (CIPO) is a rare, characterized by chronic abdominal pain with intermittent exacerbations of bowel obstruction. An attempt to surgically remove an apparent involved segment is often not recommended and is associated with potentially worse long term outcomes. CASE DESCRIPTION/METHODS: A 72 year old man, with a history of pre-diabetes and chronic constipation had first presented 5 years ago with abdominal pain. CT showed evidence of marked redundancy and gaseous distention of the sigmoid colon without evidence of mechanical obstruction. He was diagnosed with sigmoid volvulus and laparoscopic sigmoid colectomy was performed. Thereafter, he was presumably thought to have an acute exacerbation of colonic pseudo-obstruction, for which he had an elective subtotal colectomy performed. 4 months after surgery, the patient presented to our ER with abdominal pain and distention. CT showed marked gaseous distention of small bowel loops and the stomach with no evidence of structural obstruction. The patient was kept NPO and was decompressed with a nasogastric and rectal tube. Prokinetic erythromycin was started. Interval CT documented decompressed stomach, improvement in gaseous distention of small bowel loops although measuring up to 6.1 cm. DISCUSSION: CIPO is rare, with prevalence and incidence estimated to be 0.9 and 0.23 cases per 100,000, respectively. Either secondary or idiopathic, 3 underlying pathologic entities suggested for CIPO: neuropathic, myopathies or mesenchymopathy. Imaging revealing dilated small or large bowels in the abscess of anatomical obstruction is required for the diagnosis. Impaired motility supports the diagnosis. Rarely, CIPO might present with an actual anatomical obstruction, especially in the setting of previous abdominal surgeries, masking or delaying the diagnosis. Proper diagnosis of CIPO is crucial, as the mainstay of management remains treating the underlying primary condition. Despite segmental appearing disease, an attempt to selectively remove the affected area is ill-advised, as it might promote post-operative mechanical obstruction, proven inefficacious in preventing pseudo-obstruction of other segments with a probabilities of CIPO-related re-operation of 66% after 5 years. This case demonstrates the complexity of CIPO diagnosis when newly presenting with mechanical obstruction and the ineffectiveness of colectomy in preventing further exacerbations.Figure 1.: CT showing gastric pneumatosis and marked distention of the stomach containing fluid, debris, and gas with no evidence of structural obstruction from the stomach.Figure 2.: CT showing gaseous distention of small bowel loops without sharp transition point.

Gastric Emphysema With Hepatic Portal Venous Gas Secondary to Acute Gastric Mucosal Lesion

A 75-year-old man was treated with a percutaneous coronary intervention for myocardial infarction. Six hours after the percutaneous coronary intervention, his abdomen had become gradually distended. His vital signs were stable, and his abdomen was mildly tender without peritoneal signs. Contrast-enhanced computed tomography of the abdomen revealed massive air accumulation within the hepatoportal vein and gastric wall (Figure A, arrows). He was diagnosed as gastric pneumatosis with hepatoportal venous gas.

Gastric pneumatosis and its varied pathogenesis

Gastric pneumatosis and its varied pathogenesis

Five Cases of Gastric Pneumatosis in Black and White Ruffed Lemurs (Varecia variegata)

Five Cases of Gastric Pneumatosis in Black and White Ruffed Lemurs (Varecia variegata)

A rare case of gastric pneumatosis in a seven-month-old infant – case report

A rare case of gastric pneumatosis in a seven-month-old infant – case report

A Rare Case of Gastric Cystic Pneumatosis Associated With Drug-Induced Gastric Injury

A 47-year-old man with history of cocaine addiction was hospitalized after cardiac arrest. Cardiopulmonary resuscitation associated with subsequent doses (3+6+6 mg) of ephedrine was performed. Upon intensive care unit admission, he presented with postanoxic encephalopathy, hyperpyrexia, disseminated intravascular coagulation, and multiorgan failure. Drug screening detected benzoylecgonine (57 ng/mL–1), ephedrine (73 ng/mL–1), 3,4-methylenedioxymethamphetamine, 3,4-methylenedioxyamphetamine, delta-9-tetrahydrocannabinol, and morphine.