Case Report: Hirsch, Herman

Emphysematous Gastritis and

Its Differential Considerations
Daniel Hirsch, M.D., Steven D. Herman, M.D.

Department of Radiology, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA

Case Presentation
A 68-year-old diabetic woman presented to the emergency department complaining of a 1-day history of generalized
abdominal pain, coffee ground emesis, and dark stools. She was found to be afebrile but hypotensive. Physical exam-
ination was remarkable for abdominal distention and generalized tenderness to palpation. Laboratory findings revealed
leukocytosis. The patient was further evaluated with a noncontrast computed tomography (CT) examination of the ab-
domen and pelvis due to concern for diverticulitis or possible perforation (Figure 1).

A B

C D

FIGURE 1. Axial (A), coronal (B), and sagittal (C)

unenhanced computed tomography (CT) images of
the abdomen demonstrate marked gastric disten-
tion and wall thickening with intramural gastric air
along the greater curvature (arrows). An intraopera-
tive photo from subsequent surgical intervention (D)
reveals focal areas of gastric necrosis (arrows).

J Am Osteopath Coll Radiol 2017; Vol. 6, Issue 3 Page 19

 Case Report: Hirsch, Herman
Key Imaging Finding(s)
Intramural gastric air
Differential Diagnoses
Soft-tissue sarcoma
Emphysematous gastritis
Gastric emphysema
Iatrogenic/traumatic injury
Nongastric source
Discussion
Gastric intramural air is a rare radio-
logic finding with causative etiologies
ranging from benign and self-limiting
to potentially lethal. It typically occurs
when the gastric mucosa is disrupted,
allowing for air to track between the
various layers that compose the stom-
ach wall. While different imaging
modalities may reveal associated patho-
logic findings, CT is the most sensitive.
Several etiologies of intraluminal gas-
tric air have been described in the liter-
ature, and distinguishing between them
is necessary as they are distinct patho-
logic entities with varying prognoses
and management strategies.
Emphysematous Gastritis
First described in 1889, emphysem-
atous gastritis is the result of gas-form-
ing organisms that colonize the gastric
mucosa, most commonly Klebsiella
pneumonia, Escherichia coli, Pseudo-
monas aeruginosa, and Enterobacter
subspecies. 1 Diabetes, immunosup-
pression, and alcohol abuse have all be
reported as predisposing factors.2 Clin-
ical presentation is variable and often
includes nausea, vomiting, mild to se-
vere abdominal pain, hematemesis, and/
or melena.3 Most reported cases have
followed an acute to subacute clinical
presentation. Radiologic evaluation is
typically performed with CT, which
demonstrates a streaky and linear pat-
tern of distribution of air within the gas-
tric wall. The location of the gas does
not change with patient positioning,
confirming that it is located within the
gastric wall. Additional associated find-
ings include gastric wall thickening and
the presence of portal venous gas. Man-
agement depends on patient stability.
Page 20
Patients often become toxic, prompting
surgical intervention. However, several
cases have described successful con-
servative management of an otherwise
stable patient with bowel rest and gram
negative and anaerobe antibiotic cov-
erage. Overall prognosis is poor, with
mortality rates of 60% to 80%.4
Gastric Emphysema
Gastric emphysema is often used to
refer to a noninfectious source of intra-
mural gastric air. It is often seen in the
setting of chronic inflammation such as
gastroenteritis or any process with in-
creased intraluminal pressure, including
gastric outlet obstruction, small bowel
obstruction, or forceful vomiting.2 As
with emphysematous gastritis, these
patients will demonstrate linear hy-
podensities along the gastric wall on CT,
although there is typically no wall thick-
ening or portal venous gas. It is primarily
the clinical picture that differentiates the
two entities, as these patients will often
be asymptomatic and hemodynamically
stable. Gastric emphysema is usually
self-limited and requires no intervention.
Iatrogenic/Traumatic Injury
Many different iatrogenic or trau-
matic mechanisms have been described
in the literature that may result in intra-
mural gastric air, including nasogastric
tube placement, laparoscopic gastric
band erosion, and motor vehicle acci-
dents.5-7 Additionally, ingesting caus-
tic substances may damage the gastric
lining, allowing for the presence of in-
tramural air. While alkaline and acidic
substances will vary in their mechanism
of insult (ie, coagulative vs. liquefactive
necrosis), they both result in mucosal
damage and possible superinfection
with gas-forming bacteria.8 Similar to
emphysematous gastritis, hemodynam-
ically unstable or rapidly deteriorating
patients benefit from prompt surgical
intervention, while stable patients may
be managed conservatively.
Nongastric Source
Air within the gastric wall does not
necessarily have a gastric origin, as
J Am Osteopath Coll Radiol 2017; Vol. 6, Issue 3
cases of air tracking from adjacent sites
to include the gallbladder 9 or bowel
have been reported. A common non-
gastric source of gastric intramural air
is from the pulmonary system. Several
studies have described the presence of
intramural gastric air in the setting of
bullous emphysema, specifically after
rupture of alveoli.10 This allows free
air to dissect along the vascular sheaths
and reach the paraesophageal space,
ultimately tracking down and settling
within the gastric mucosa. Patients in
this category typically demonstrate no
abdominal symptoms and the finding is
often made incidentally.
Patient Management
Due to the CT findings and the pa-
tient’s continued decompensation, she
underwent a partial gastrectomy and
focal areas of gastric necrosis were
found. Both gastric tissue and perito-
neal fluid samples were positive for
Staphylococcus epidermidis and Enter-
coccus faecalis.
Diagnosis
Emphysematous gastritis
Summary
Gastric intramural air is a rare but
important radiologic finding that is best
appreciated on CT. Multiple pathologic
mechanisms have been described, each
of which carries a different prognosis
and management strategy. Familiar-
ization with the various etiologies, as
well as a detailed clinical history, is
crucial in making the correct diagnosis
and guiding appropriate management.
The most severe form, emphysematous
gastritis, refers to an infectious source
resulting in the formation of gas within
the gastric mucosa. If not promptly di-
agnosed and treated, it has a high rate of
mortality.
References
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Case Report: Hirsch, Herman
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