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Abstract

INTRODUCTION

Emphysematous gastritis is a rare and serious condition characterized by evidence of intramural air and inflammation of the gastric wall as well as systemic toxicity. It is generally caused by local infection by gas-forming organisms through a mucosal defect or via hematogenous spread from a distant focus.1 Since emphysematous gastritis has a fulminant course with a mortality rate of 60%, prompt recognition as well as early treatment are crucial.2 Here, we present a case of a 65 year-old male who presented with abdominal pain and had CT findings consistent with emphysematous gastritis. He was treated with antibiotics and had a swift recovery.

CASE PRESENTATION

A 65-year-old Caucasian man with past medical history of insulin-dependent diabetes, hypertension, hyperlipidemia, coronary artery disease (with history of three myocardial infarctions and stent placements), and peptic ulcer disease presented to Thomas Jefferson University Hospital with two weeks of loose stools and two days of nausea, vomiting and diffuse abdominal pain. In the emergency room, the patient had a temperature of 96.8oF, heart rate of 99 beats per minute, blood pressure of 95/58 mmHg, respiratory rate of 22 breaths per minute, and oxygen saturation of 96% on 3L of oxygen. His cardiac and respiratory exams were unremarkable. His abdominal exam was notable for hypoactive bowel sounds and pain with deep palpation. He was tympanic to percussion. He did not have peritoneal signs. Labs were significant for a white blood cell count of 11.3 B/L (normal range = 4-11 B/L) and lactate of 1.0 mmol/L (normal range = 0.5-2.2 mmol/L) on presentation, which was repeated 6 hours later and found to have increased to 2.5 mmol/L. He underwent a CT scan of the abdomen which revealed a distended stomach with foci of intramural air, with air extending into the portal venous system (Figure 1). Soon after presentation, the patient became hypotensive to a systolic blood pressure of 85 mmHg and was resuscitated with 3L normal saline. He was sent to the intensive care unit where he received an additional 2L normal saline. His blood pressure responded appropriately. Surgery was consulted regarding the intramural air found on CT scan. However, since the patient did not have an acute abdomen, they deemed that he would not need emergent surgery. It was also decided that an esophagogastroduodenoscopy (EGD) would be too high risk given the increased risk of perforation. He was medically managed with antibiotics and supportive care. He was allowed nothing-by-mouth, pan- cultured, and started on a pantoprazole infusion and broad spectrum antibiotics (vancomycin, aztreonam, and metronidazole.

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