Emphysematous gastritis with gastric perforation

Case contributed by Raihanah Haroon
Diagnosis almost certain

Presentation

Fever, lethargy, abdominal discomfort and UTI symptoms

Patient Data

Age: 80
Gender: Male

CT show fluid-distended stomach with gross thinning of the gastric wall mainly involving the greater curvature of the stomach with intramural gas within representing gastric pneumatosis. Minimal surrounding air pockets and mesenteric streakiness are also seen. The normal enhancement of the gastric mucosa at this region is also not demonstrable. Few foci of free air at this region, suggesting evidence of perforation.

Concomittant non-enhancement of the entire spleen is not enhanced with non-opacification of the distal segment of the splenic artery, suggestive of thrombosis. 

Incidental finding of innumerable tiny cortical renal cysts bilaterally.

 

Case Discussion

Emphysematous gastritis is rare, partly due to the acidity of gastric juice, rendering the gastric mucosa to be fairly resistant to infection. This condition is best evaluated by CT. 

Several factors have been described in previous literature which predispose the stomach to this condition, including diabetes mellitus, rheumatic diseases, treatment with corticosteroids or previous abdominal surgery.

Clinical presentations include abdominal pain, nausea, vomiting, hematemesis and melena. Invading organisms dissect along the plane of muscularis mucosa of the stomach and hence yielding necrotic tissue within nasogastric aspirate or emesis, which is pathognomonic for this condition. This is a lethal type of infection which carries poor prognosis with mortality rate of about 60%. .

In our case, the etiology is possibly multifactorial; which include ongoing sepsis and gastric infarction since concurrent splenic infarction was also observed. Subsequent fungemia occured and patient succumbed.

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