Successful medical management of emphysematous gastritis

SESSION TITLE: Critical Care Case Report Posters 11 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Emphysematous gastritis (EG) is an exceptionally uncommon diagnosis with a high mortality rate, with fewer than 200 cases reported in medical literature (1). It is characterized by air in the gastric mucosal wall identified on radiologic imaging. Compromise of the mucosal wall allowing entry of air may occur with infection, ischemia, recent abdominal surgery, or ingestion of toxic agents. We present a case of idiopathic EG successfully treated with medical management. CASE PRESENTATION: A 67-year-old male with type II diabetes and coronary artery disease presented to the emergency department with severe abdominal pain and hematemesis. He was tachycardic, afebrile and normotensive. Physical exam was significant for a distended, diffusely tender abdomen. Laboratory studies revealed acute kidney injury with creatinine level of 3.81 mg/dL, acute anemia with hemoglobin of 8.7 g/dL, and an elevated serum lactate of 3.9 mmol/L. Computed tomography (CT) scan of the abdomen revealed extensive intramural gastric emphysema and portal vein gas extending to the mesenteric veins. Upon diagnosis of EG, surgery and gastroenterology were consulted. Medical management including bowel rest and supportive care was recommended as the diffuse nature of the gas classified the patient as a poor operative candidate.Broad spectrum antibiotics were initiated. The patient was intubated for airway protection due to hematemesis. A nasogastric tube was placed for decompression, per the surgeon's recommendations. Repeat CT scan four days later showed improvement with a small volume of residual intramural gas and resolution of portal venous gas. The patient tolerated enteral feeding and was stable for discharge after a 14-day hospitalization. Blood cultures remained negative, and a definite cause of his EG was not identified. DISCUSSION: A review of EG cases published since 1998 shows increased survival rate with early recognition and conservative treatment. Surgical intervention was previously a mainstay of therapy, however now is often avoided due to the risk of poor healing of the friable, inflamed mucosa (2). The most common cause of EG appears to be infection with gas-producing organisms such as Streptococcus, Staphylococcus, and Clostridium species. Therefore, it is imperative to obtain blood cultures and initiate broad-spectrum antibiotics. The low pH of the stomach creates an environment resistant to most infections, contributing to the uncommon nature of EG (3). Agents that disrupt the stomach's pH such as proton pump inhibitors may increase the risk of mucosal barrier disruption. CONCLUSIONS: EG is a rare, often fatal diagnosis. Healthcare providers should be aware of the increased mortality of surgical intervention, and guidelines should be established for medical management. Gastrointestinal infections are often gram-negative in origin, however broad-spectrum coverage is essential as gas-producing pathogens known to cause EG are often gram-positive. REFERENCE #1: Asharaf A, Desai P, Sanati M. Emphysematous Gastritis. The Journal of the American Osteopathic Association; 2019. p. 848. REFERENCE #2: Bashour CA, Popovich, Marc J., Irefin, Samuel A., Esfandiari, Shapour, Ratfliff, Norman B., Hoffman, William D., Averbrook, Allen W. Emphysematous gastritis. 1998. p. 716-718. REFERENCE #3: Elson MZ, Monzón LL, Orta JE, Fierro PC, Monteverde VV, Arbeloa CS. Emphysematous gastritis: Effectiveness of early antibiotic therapy. Gastroenterology and Hepatology. 2016;39(6):393-395. doi:10.1016/j.gastre.2016.02.017 DISCLOSURES: No relevant relationships by Amanda Cecchini No relevant relationships by Arthur Cecchini No relevant relationships by Mohammad Darweesh No relevant relationships by Joshua Sill, value=Honoraria Removed 03/15/2023 by Joshua Sill, source=Web Response