Emphysematous gastritis: a terrifying presentation
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A 54-year-old woman with a known history of excessive alcohol ingestion (20?g/day) and depression was admitted to the emergency room with epigastric pain, haematemesis, and melena. A physical examination, she was found severely ill, with cold extremities and a distended abdomen. Hypotension (80/50?mm Hg), tachycardia (160/min), and lower temperature (34°C) were presented.

Blood tests showed anemia, leucocytosis with neutrophilia 76% and elevated levels of C reactive protein. Aspartate aminotransferase (AST) was in the upper limit of normal range (53?U/L, 12–40). Acute renal lesion (pCr 1.9?mg/dL) was also present. A nasogastric tube was placed and a massive amount of blood and gas was drained off. After the admission, the patient initiated intravenous fluid resuscitation and broad-spectrum intravenous antibiotherapy (ceftriaxone 2?g and metronidazole 1.5?g).

Abdominal CT scan showed marked gastric distension and presence of mottle gas in the gastric wall, findings consistent with emphysematous gastritis. No portal venous gas was seen. A fishbone was also identified. The axial and coronal views demonstrated marked stomach distention and the presence of intramural gas. Coronal view allowed us to see fishbone embedded in the gastric fundus. The absence of pneumoperitoneum excludes the existence of transmural perforation. Other findings such as ascites, pleural effusion, and stranding fat tissue were also found.

A life-saving total gastrectomy was performed with an esophagus-jejunal anastomosis. Unfortunately, the patient died in the next week due to anastomosis dehiscence. Later, in the blood culture, an Escherichia coli was isolated. Emphysematous gastritis is a rare entity with a high mortality rate. This pathology is classified as a subtype of phlegmonous gastritis, caused by gastric producing organisms. The gastric mucosa has a rich blood supply with a low pH. These characteristics produce a resistant barrier to infection, explaining the existence of a trigger to disrupt integrity.

A correct and thorough investigation should always be made for other predisposing factors like corrosive substances (bases and acids), alcohol abuse, abdominal surgery, diabetes, and nonsteroidal anti-inflammatory drugs (NSAID) abuse. The clinical presentation is usually ominous and fulminant with abdominal pain, nausea, and vomiting as well as shock. The patient besides the abuse of alcohol and antidepressive drugs also presents a foreign body. Necrotic tissue in emesis or nasogastric aspirate is considered the main finding, resulting from the dissection of the muscular mucosa. A definite diagnosis can be made by the presence of intramural gas with a CT abdominal scan. Ultrasound is also very sensitive to the detection of portal venous gas.

Antibiotics covering gram-negative organisms and anaerobes should always be tried, accompanied by surgery which may enhance survival. Intravenous fluids provide an essential part of hemodynamic stabilization.