MD University of Iowa hospital and clinics, United States
Introduction: Emphysematous gastritis is a rare and often fatal form of gastritis characterized by the presence of gas, hemorrhage and inflammation within the stomach wall, caused by gas forming bacteria. To date there are only 91 cases of emphysematous gastritis reported in English literature. We present the case of a patient without systemic toxicity who survived this condition with conservative treatment.
Description: 83 y/o M with history of well controlled T2DM, and myelodysplastic syndrome who presented with dyspnea for 1 week, progressive, increasing edema of lower extremities, worsening abdominal symptoms including pain, Nausea, vomiting, diarrhea, melena, distension for 1 week. CT abdomen revealed gastric emphysema with mesenteric and portal venous gas. Admission vitals were unremarkable. Labs on admission - BUN 21, Cr 1.15, Glu 199, WBC 5.9, Hb 8.5, Plt 130, lactic acid 2.7. Patient was started on Zosyn, daptomycin and caspofungin. Upper endoscopy revealed findings concerning for emphysematous gastritis, fluid aspirate, tissue samples were sent for analysis, and patient was started on protonix IV. General Surgery recommended no surgical treatment. Blood cultures were negative but cultures from the gastric, duodenal aspirates revealed Candida albicans, Streptococcus mitis/oralis group, and Corynebacterium argentoratense. Pathology revealed hemorrhage and air spaces in the lamina propria and some bacteria in gram stain. Antibiotics were deescalated to oral amoxicillin-clavulanate and fluconazole. Patient improved without further complications, he tolerated diet. He was discharged with ID follow up.
Discussion: Emphysematous gastritis is a rare but potentially lethal condition with a mortality rate that ranges from 55-60%. It is caused by gas forming organisms such as E.coli, Streptococci, Enterobacter species, S.aureus, etc. Patients typically present with signs of systemic toxicity, shock, fever, nausea, vomiting, acute abdominal pain, with or without hematemesis and melena. Predisposing factors include corrosive ingestion, alcohol abuse, abdominal surgery, diabetes, and immunosuppression. The diagnostic test of choice is the CT abdomen. Upper endoscopy with biopsies is used to confirm diagnosis. Treatment includes antibiotics, supportive management and in selected cases surgery.
