Ephemeral emphysema
68-year-old female presented with abdominal pain, distention, and vomiting. Imaging revealed gastric emphysema secondary to gastric distention, managed conservatively with nasogastric tube insertion and IV fluids. Learn about the causes, diagnosis, and resolution of this rare condition.
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Ephemeral emphysema Sahithi Nishtala, Biju Thomas , Anitha James, Ravivarma Balasubramaniam, Ingrid Britton, Nicola Cook, Vincent Leung, Nabil Sherif Mahmood University Hospitals of North Midlands NHS Trust sahithinishtala@gmail.com
Clinical Presentation 68 year old female. Previous laparotomy and formation of colostomy for acute sigmoid volvulus. Admitted with abdominal pain, distention and vomiting. On examination: Tender but not peritonitic No stoma output Bowel sounds present
Contrast enhanced CT abdomen and pelvis Fig 1(a) Fig 1(a) and (b)showing a markedly distended stomach and extraluminal gas locules Fig 1(b)
In addition, there is portal venous gas as seen on Fig 1c and d. No other abnormality to account for the portal venous gas or the patients symptoms. Differential diagnosis: Mesenteric ischaemia Fig 1 ( c) Emphysematous gastritis Gastric emphysema Fig 1(d)
Biochemistry Arterial blood gas: Ph 7.44 Lactate 1.3 mmol/L CRP 21 mg/L WCC 12.6 x 109/ L Liver and Renal function tests -Normal
Management Patient was conservatively managed as the clinical picture did not support ischaemic bowel. Repeat imaging 4 days later
Repeat CT 4 days later showed resolution of the portal venous gas, pneumoperitoneum and intra mural gastric gas.
Diagnosis Gastric emphysema secondary to gastric distention, which resolved with conservative management of nasogastric tube insertion and intravenous fluids
Gastric emphysema Emphysematous gastritis Benign High mortality Conservative management(usually) Requires aggressive/immediate management Causes Causes Gastric outlet obstruction causing dissection of air into the gastric wall Ischaemia Infection due to gas forming gram negative organisms Rupture of pneumothorax/pneumatic bulla Iatrogenic, following instrumentation Associated with portal venous gas Associated with portal venous gas
How do we differentiate between the two? Look at the patient! Patient usually well in gastric emphysema and can be managed conservatively. Critically unwell with emphysematous gastritis or ischaemia and require aggressive management. Emphysematous gastritis usually seen in diabetics.
Key learning points Gastric emphysema and ischaemia have similar radiological appearances. Portal venous gas is seen in both conditions. However gastric emphysema can have a benign course and despite the worrying imaging appearances can be managed conservatively, avoiding unnecessary intervention. Correlation with clinical examination and biochemical parameters is of paramount importance to reach the correct diagnosis.
References A Misro, H Sheath; Diagnostic dilemma of gastric intramural air. Annals of Royal College of Surgeons England. 2014 Oct; 96(7): e11 e13 van Mook WN, van der Geest S, Goessens ML et al. Gas within the wall of the stomach due to emphysematous gastritis: case report and review. Eur J Gastroenterol Hepatol 2002; 14: 1,155 1,160 Paul M, John S, Menon MC et al. Successful medical management of emphysematous gastritis with concomitant portal venous air: a case report. J Med Case Rep 2010; 4: 140. G Lopez Medina et al; Gastric Emphysema a Spectrum of Pneumatosis Intestinalis: A Case Report and Literature Review. Case Reports in Gastrointestinal Medicine Volume 2014 (2014), Article ID 891360
