Presentation
Acute onset of abdominal pain in an elderly patient.
Patient Data
An 80-year-old female patient was admitted in respiratory distress following a house-fire. She was intubated on admission. A diagnosis of anoxic brain injury secondary to smoke inhalation in addition to carbon monoxide poisoning was made.
A wide bore suction NG was placed in the ICU shortly after admission to decompress the stomach. Her condition stabilized, she was extubated and was discharged from ICU to a non-acute ward on day 3. Oral feeding was deemed unsafe on formal swallow assessment and on day 10, her wide bore suction NG was exchanged for a feeding NG tube. She subsequently received her daily nutrition via this tube. The NG tube required multiple reinsertions due to accidental dislodgement (as a result of the patient’s confused state). She underwent multidisciplinary rehabilitation over the following weeks.
On day 34, the patient became unsettled and appeared to be in some pain. As a result of the anoxic brain injury, she was unable to verbalise, making clinical assessment difficult. On examination, she recoiled to deep palpation throughout the abdomen. Her vital signs and routine blood tests were stable when compared with baseline measurements.
Abdominal radiograph as the first-line investigation for new-onset abdominal pain.
This study demonstrates mottled lucency in the left upper quadrant. The bowel gas pattern is otherwise within normal limits.
CT performed on the basis of findings on the abdominal radiograph.
This study demonstrates large amounts of intramural gas in the stomach, in keeping with gastric emphysema (gastric pneumatosis). The intramural gas is localized to the anterior stomach wall. Pockets of extramural gas are also seen in the fat anterior to the stomach suggesting localized perforation (see key image). The stomach is not overdistended. There is no portal venous air and no pneumatosis involving small or large bowel.
Following surgical consultation, the patient was managed conservatively and her condition settled clinically over the following days.
A repeat CT abdomen-pelvis was performed 18 days later, demonstrating complete resolution of the previously identified gastric emphysema and of the extramural free air anterior to the stomach
I wish to acknowledge the contribution of Dr Suzanne Shine, Consultant Radiologist, and Dr Jan Gerstenmaier, Radiology Registrar, St. Vincent's University Hospital, Dublin, Ireland.
Case Discussion
Gastric intramural air is a rare entity. It should be considered in the presence of an unusual gas pattern in the left upper quadrant on an abdominal radiograph. In many cases, the stomach circumference is outlined with linear lucencies. In others, such as our case, the intramural air is more localized and a mottled gas pattern is seen in the left upper quadrant. A CT scan will confirm the presence of air in the stomach wall, demonstrate the extent, show portal venous air if present and may also give valuable information regarding the underlying cause.
Gastric emphysema has many etiologies which can be broadly divided into gastric and extragastric causes. Emphysematous gastritis is clinically distinct from the other causes as the patient is seriously ill and has a poor prognosis. On the contrary, other causes of gastric emphysema usually respond well to conservative management and the condition tends to resolve spontaneously, as was the case with our patient. Zenooz et al1 report a case of gastric emphysema secondary to intramural nasogasrtic tube placement.
I wish to acknowledge the contribution of Dr Suzanne Shine, Consultant Radiologist, and Dr Jan Gerstenmaier, Radiology Registrar, St. Vincent's University Hospital, Dublin, Ireland.
Unable to process the form. Check for errors and try again.