The finding of gas within the gastric wall is not a disease by itself, rather than a sign of an underlying condition which could be systemic or gastric. We present the case of a woman identified with gastric emphysema secondary to the administration of high doses of steroids, with the purpose of differentiating emphysematous gastritis versus gastric emphysema due to the divergent prognostic implications. Gastric emphysema entails a more benign course, opposed to emphysematous gastritis which often presents as an acute abdomen and carries a worse prognosis. Owing to the lack of established diagnostic criteria, computed tomography is the assessment method of choice. Currently no guidelines are available for the management of this entity, since the evidence is limited to a few case series and a considerable number of single case reports.
Radiologic detection of gas within the wall of the gastric chamber is not an entity per se but a sign of an underlying disease [
We present a 44-year-old woman with history of mixed connective tissue disease, who was hospitalized due to exacerbation of her underlying condition for which she was treated with high dose pulses of methylprednisolone. Two days after discharge she arrives back to the emergency room, complaining mainly of abdominal pain located on upper quadrants, not related to food ingestion, associated with vomiting of gastric content in four occasions and one liquid stool free from mucus or blood. At admission with stable vital signs, without acute abdomen or other relevant findings revealed on physical examination, stool specimens, blood analyses, and cultures analyses were requested in search for infectious origin, resulting negative. The plain abdominal X-ray showed a radiolucent image in the left upper quadrant (Figure
Plain abdominal X-ray. Radiolucent image in the upper left abdominal quadrant, showing the presence of air within the wall of the stomach (arrow).
Plain chest X ray. Radiolucent image below the left diaphragm showing the presence of air within the wall of the stomach (arrow).
Abdominal scout image from a computed tomography.
Computed axial tomography of the abdomen with oral contrast agent enhancing the stomach.
Computed axial tomography of the abdomen with oral and intravenous contrast agent enhancing the stomach during the arterial phase.
Fasting was indicated as well as management with proton bomb inhibitor and broad spectrum antibiotic ampicillin/sulbactam. After twelve hours of close monitoring, the patient persisted nauseous and vomiting, therefore, underwent a liberating mucotomy via superior endoscopy, without complications and minimum bleeding. However, 24 hours later the patient continued presenting abdominal pain and under the suspicion of gastric perforation, due to the presence of right subdiaphragmatic air on a chest X-ray, she was taken to the operating room for an exploratory laparotomy revealing free hematic fluid in the abdominal cavity; methylene blue dye was instilled into the gastric lumen without evidence of dye extravasation, concluding the absence of perforation, considering the procedure complete. Afterwards the evolution was torpid showing signs of rheumatologic activity associated to acute pulmonary deterioration that led to the patient’s death due to a possible hemorrhagic alveolitis.
The pathogenesis of this disease has been debated for decades; however, it may be approached through the questions, where did the gas come from? And how did it get there? Based on these are how three mechanisms of origin are proposed: (1) intraluminal, (2) bacterial production, and (3) gas of pulmonary origin [
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 [
It has been postulated that emphysematous gastritis is produced by gas forming bacteria and gastric emphysema by air dissecting the wall [
When the origin of the gas is intraluminal, pneumatosis can occur even alongside an intact mucosa, with intraluminal high pressure accounted as the responsible mechanism. In the context of an injured mucosa, because of trauma or inflammation, a normal intraluminal pressure may be present or a combination of both [
In the case gas derives from bacteria, the theory of counterperfusion-supersaturation has been postulated, and it sustains that the production of nitrogen by intraluminal bacteria overflows the plasma concentration producing a plasma-intraluminal gradient and causing a diffusion of nitrogen into submucosal vessels which would explain the gas pattern found through the blood vessels in the border of the mesentery [
A pulmonary source has also been debated. The proposed theory is that air travels from an alveolar rupture into the blood vessels up to the gastrointestinal tract. Nevertheless the absence of interstitial emphysema in the mesentery has called this theory into question, giving place to a hypothesis of an increase in intraabdominal pressure hence intraluminal pressure, frequently seen in chronic cough patients causing transmural migration of air [
Resuming the etiopathogenesis of this entity, some causes can be mentioned in referral to gastric processes associated to injury of the mucous wall of the stomach. It is well known that acute gastric distension can result in gastric emphysema, emphysematous gastritis, or necrosis. Massive distension causes ischemia with extension of intraluminal gas in to the wall [
Pneumatosis can also result from a variety of extragastric processes, which favor air migration thru the wall of the colon despite maintaining intact. That being said we can include chronic pulmonary obstructive disease, polymyositis, perforated appendicitis, small bowel volvulus, intestinal infarction, gangrenous cholecystitis, superior mesenteric artery syndrome, cholangiocarcinoma, parastomal hernia, and multiple episodes of vomiting. In relation to drug related background, it has been linked to chemotherapy agents such as cyclophosphamide, adriamycin, and vincristine, in addition to high doses of dexamethasone in one case report [
Clinical manifestations are usually nonspecific, presenting with nausea, vomit occasionally resistant to antiemetics, mild to severe abdominal pain, abdominal distension, haematemesis, or melena; presentation as an acute abdomen is rare [
Among the image battery available, computed tomography (CT) of the abdomen is the method of choice since it can detect a minimum amount of air inside the wall of the gastrointestinal tract and evaluate the abdominal cavity. Gastric emphysema is presented as a hypodense lineal or curve fringe on the gastric wall along with distension, without evidence of thickening of the wall. Occasionally pneumoperitoneum may be detected, in contrast to emphysematous gastritis where a streaky and linear pattern distribution of air and gastric wall thickening are characteristic, or air in some other bowel or biliary tract can be found [
There is no available standard treatment for this condition; most of the reported cases have been treated in a conservative manner. A retrospective study by Morris et al. [
The prognosis of gastric emphysema is usually benign with spontaneous resolution even without a specific treatment [
Gastric emphysema and emphysematous gastritis are spectrum of intestinal pneumatosis; both belong to the least common forms of presentation, with different etiopathogenic possibilities (traumatic, inflammatory, or mechanic), systemic impact, intraabdominal findings, and prognosis and with a distinctive feature of gastric emphysema that in most cases yields more indolent behavior. It is maintained as a misunderstood pathology, in great part since most of the evidence derives from single case reports and series in a significant number of clinical scenarios.
The main suspicion in the presented case was an inflammatory cause which was sustained by the presence of hematic ascites, not rare in patients with connective tissue diseases. The implemented measures of endoscopic mucotomy plus coverage by board spectrum antibiotics turned out in a positive impact regarding the gastrointestinal aspect, unlike the rest of the progression of her base rheumatologic disease.
The review of this case was presented to and approved by the Hospital’s Ethics Committee.
The authors declare that there is no conflict of interests regarding the publication of this paper.
All authors have contributed in terms of material, images, and review of the final document.