University of Maryland Medical Center Midtown Campus Baltimore, MD
Mohammed Rifat Shaik, MBBS1, Chet Ranabhat, MBBS1, Nishat Anjum Shaik, MBBS1, Zaid Bilgrami, MD2, Robert Chow, MD, MBA1, Guofeng Xie, MBBS, PhD3 1University of Maryland Medical Center Midtown Campus, Baltimore, MD; 2New York Presbyterian Hospital, New York, NY; 3University of Maryland School of Medicine, Baltimore, MD
Introduction: Gastric pneumatosis, the presence of air dissecting the gastric wall, is rare and can pose a diagnostic dilemma as it can be associated with gastric emphysema and emphysematous gastritis. While gastric emphysema has a favorable prognosis, emphysematous gastritis is a potentially life-threatening condition with a poor prognosis. Clinical correlation and disease severity are crucial to differentiate between these two accurately. We present a young woman who developed gastric emphysema due to prolonged vomiting associated with diabetic ketoacidosis (DKA).
Case Description/Methods: A 29-year-old female with a history of uncontrolled type 1 diabetes mellitus (DM) presented with abdominal pain, nausea, and multiple episodes of vomiting. She had eight hospitalizations in the previous two years for DKA. She was tachycardic and had generalized abdominal tenderness without guarding or rigidity. Laboratory tests revealed a normal white cell count of 10.0 × 109/L and an anion-gap ketoacidosis, suggesting DKA (see table). CT abdomen with IV contrast demonstrated a distended stomach and pneumatosis of the gastric fundus and proximal gastric body (Figure: images A and B). Treatment was initiated per the DKA protocol. She was placed on strict NPO status and an NG tube for gastric decompression. Intravenous ciprofloxacin and metronidazole were initiated to cover potential enteric organisms. She gradually improved, and a repeat CT abdomen on day four showed a decrease in gastric pneumatosis (Figure: images C and D). She was transitioned to an oral diet, and a close follow-up was arranged with her endocrinologist.
Discussion: Gastric emphysema occurs when there is a breach in the integrity of the stomach wall caused by various factors, such as massive gastric distention, caustic substances, perforating ulcers, and injuries from procedures like endoscopic biopsy. In contrast, emphysematous gastritis refers to an infectious form of gastritis where intramural gas is produced as a result of microbial metabolism. Patients with gastric emphysema are usually clinically stable, while those with emphysematous gastritis are often severely ill and display signs of toxicity and hemodynamic instability. Our patient's poorly controlled DM and abdominal examination led to initial suspicion of emphysematous gastritis. However, early initiation of antibiotics and supportive management helped the patient recover without needing more invasive treatment, suggesting this was indeed gastric emphysema.
Figure: Table: Coronal (A) and axial (B) images from the initial CT of the abdomen and pelvis with IV contrast demonstrate a distended stomach with pneumatosis (yellow arrows) within the gastric wall involving most of the stomach. No pneumoperitoneum, portal venous gas, or pneumatosis within the small or large bowel was identified.
Coronal (C) and axial (D) images from CT of the abdomen and pelvis with IV and oral contrast taken on day four following the initial scan demonstrating oral contrast and an enteric tube (white arrow) within the stomach with near interval resolution of gastric pneumatosis. Residual pneumatosis in the wall of the anterior antrum (yellow arrows) is noted.
Disclosures:
Mohammed Rifat Shaik indicated no relevant financial relationships.
Chet Ranabhat indicated no relevant financial relationships.
Nishat Anjum Shaik indicated no relevant financial relationships.
Zaid Bilgrami indicated no relevant financial relationships.
Robert Chow indicated no relevant financial relationships.
Guofeng Xie indicated no relevant financial relationships.
Mohammed Rifat Shaik, MBBS1, Chet Ranabhat, MBBS1, Nishat Anjum Shaik, MBBS1, Zaid Bilgrami, MD2, Robert Chow, MD, MBA1, Guofeng Xie, MBBS, PhD3. P2779 - Diabetes Mellitus and Severe Vomiting: A Recipe for Gastric Pneumatosis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
