Medical Management for Emphysematous Gastritis: Is It Time for a Standardized Approach?

Abstract

Emphysematous gastritis (EG) is a rare form of gastritis with a high mortality rate caused by gas-forming organisms that infect the stomach wall. Due to the rarity of the condition, no established management guidelines exist. Historically, surgical exploration was favored, but more recently, the management has shifted to a non-surgical approach with antibiotics, gastric decompression, and bowel rest. Here, we detail the case of a 55-year-old male with EG in which medical management alone led to the complete resolution of his illness without complication. This case supports the efficacy of a medical management strategy for EG and highlights the duration of empiric antibiotics, the role for gastric decompression, bowel rest, and parenteral nutrition, and may guide a future standardized approach to treatment.

Introduction

Emphysematous gastritis (EG) is a rare but potentially fatal gastrointestinal disease caused by gastric intramural pneumatosis. Common bacterial culprits include Clostridium perfringens, Clostridium welchii, Escherichia coli, Staphylococcus aureus, or Streptococcus species.^1,2 The disease has a high mortality rate of 33% for cases reported after 2000. ³ While clinical presentation can vary, most present with fulminant abdominal pain, hematemesis, peritonitis, and sepsis. ² Predisposing factors include trauma, abdominal surgery, alcohol use, immunosuppression, and diabetes. ¹ Diagnosis for EG relies on computed tomography (CT) which is highly sensitive and thus the gold standard.^4,5 In cases of diagnostic uncertainty, esophagogastroduodenoscopy (EGD) can be utilized but procedural risks must be weighed.^6-8 Before 2000, treatment for most cases of EG involved surgical exploration and management with gastrectomy or partial gastrectomy. More recently, treatment has shifted to a nonsurgical approach ⁹ and includes empiric antibiotics, bowel rest, parenteral nutrition, and gastric decompression.^10,11 While a literature review on EG demonstrates cases of successful medical management, currently no guidelines exist in support of this treatment strategy for this highly lethal condition.^8,10,11 More specifically, it is not known how long antibiotics should be administered, the duration of bowel rest/nutritional support, and whether re-imaging is necessary to document resolution. This case report supports a growing body of evidence demonstrating the successful treatment of EG with a nonsurgical approach. In addition, we provide a duration of antibiotics, bowel rest, and a guide for how these decisions were made in hopes that treatment for this condition can become standardized in the near future.

Case Report

A 55-year-old male with a history of severe chronic obstructive pulmonary disease on 6 L oxygen at baseline, obesity hypoventilation syndrome, heart failure with preserved ejection fraction, and class IV obesity presented to the emergency department with a sudden onset of severe epigastric pain and coffee ground emesis. He was septic with tachycardia and leukocytosis (26 000/µL) with neutrophilia (24 000/µL). Further laboratory evaluation was remarkable for acute kidney injury (serum creatinine of 2.24 mg/dL), hyperkalemia (6.1 mmol/L), and elevated lipase (273 U/L). Lactic acid was normal. CT scan of the abdomen and pelvis without contrast showed gastric pneumatosis with perigastric fat stranding and free fluid, and portal venous gas consistent with EG (Figure 1A and B).

Figure 1.

CT scan of the abdomen and pelvis without contrast on admission demonstrating gastric pneumatosis (arrow), perigastric fat stranding, free fluid, consistent with emphysematous gastritis. (A) Transverse CT view. (B) Sagittal CT view. CT, computed tomography.

In hospital on day 1, general surgery, gastroenterology, and infectious disease services were consulted. The patient was made nothing by mouth, a nasogastric tube (NG) was placed to low intermittent suction for gastric decompression, and he was started on intravenous antibiotics with cefepime and metronidazole. He was also started on continuous intravenous crystalloid fluid and a continuous intravenous pantoprazole infusion, which was later switched to twice daily dosing for the rest of the stay. Given the improvement in tachycardia, laboratory derangements, and his symptoms within 24 hours of medical treatment, the general surgery team deferred surgical exploration and intervention. EGD was also deferred as it served no additional role in diagnosis or management. On hospital day 5, the NG tube was clamped, and a peripherally inserted central line catheter was placed to initiate total parenteral nutrition (TPN). On hospital day 7, the NG tube was removed after going 24 hours without nausea or vomiting, and he was advanced to a clear liquid diet. On hospital day 8, the patients started eating solid food, and TPN was discontinued. The patient continued to tolerate a regular diet without complications. On hospital day 15, a repeat CT scan of his abdomen and pelvis showed complete resolution of EG (Figure 2A and B), and his antibiotics were stopped. The patient was discharged home 48 hours later in improved and stable condition.

Figure 2.

Follow-up CT scan of the abdomen and pelvis showing complete resolution of gastric pneumatosis and associated inflammatory changes after 15 days of medical management. (A) Transverse CT view showing resolution of intramural gastric gas (orange arrows). (B) Sagittal CT view demonstrating resolution of gastric pneumatosis (orange arrows). CT, computed tomography.

Discussion

EG is a rare illness with fewer than 200 prior reports in the literature. ⁶ Previous case reports focused on the utility of EGD to overcome diagnostic uncertainty, complications of the illness, clinical presentation, and basic management. Due to the high morbidity and mortality associated with EG, prompt diagnosis and timely initiation of medical management are paramount.

As previously stated, the management of EG historically involved laparotomy with possible gastrectomy. Unfortunately, surgical intervention carries a high risk of complications including but not limited to fistulas, strictures, anastomotic leak, peritonitis, and death. ³ Recently, the trend has been toward medical management of EG, with surgery utilized only when medical management has failed, heralded by a gross clinical decline such as uncontrolled sepsis, perforation, and peritonitis.^12,13

Several published reports have supported success with medically managed cases. However, optimal medical treatment has not been established, and no published guidelines on treating EG exist. ¹⁴ Previous case reports describing successful medical management involve some combination of bowel rest, parenteral nutrition, gastric decompression, and intravenous antibiotics. However, the optimal duration of these is not known.

It is essential to differentiate EG from other conditions with gastric intramural gas, such as gastric emphysema (GE) and cystic pneumatosis (CP). Unlike EG, GE is typically a benign and noninfectious process, often caused by barotrauma, vomiting, or endoscopic instrumentation, and lacks systemic toxicity.^15,16 CP, though rare, is also a distinct entity that usually follows a chronic, asymptomatic course. EG, in contrast, is characterized by systemic toxicity, rapid clinical deterioration, and infection with gas-forming organisms, and requires prompt recognition and aggressive therapy.

Although EGD has been utilized in some reports with diagnostic uncertainty, its role is limited to mucosal visualization and cannot assess the gastric wall or identify intramural gas. Therefore, it is not a diagnostic tool for EG. ¹⁷ CT remains the gold standard for diagnosis, given its ability to detect gas within the stomach wall, perigastric inflammation, and portal venous gas. EGD may have a role in assessing mucosal ischemia or excluding alternative diagnoses in selected patients.

With respect to antibiotics, it appears intravenous antibiotic duration ranges anywhere from 7 days to 2 weeks. Most successful cases managed conservatively involve some anaerobic coverage, while some also include broader coverage for Gram-positive organisms and methicillin-resistant S. aureus.^8,14,15 The timing of bowel rest is also uncertain with this period ranging from 1 day to 1 week in previous case reports. Some cases involve repeat imaging before advancing diet to ensure EG resolution, while others do not.^1,8-11,14,16

In our patient, multiple predisposing factors may have contributed to the development of EG, including class IV obesity, chronic hypoxemia due to severe chronic obstructive pulmonary disease (COPD), and obesity hypoventilation syndrome, which may lead to impaired mucosal perfusion. These conditions likely created an environment favorable for gas-forming organisms to invade the gastric wall.

Our patient had 7 days of bowel rest. No imaging was repeated before advancing the diet, but we awaited a resolution of nausea/vomiting and sepsis. In our case, we opted for 14 full days of intravenous antibiotics with cefepime and metronidazole. Antibiotics were stopped when a repeat CT scan of the abdomen and pelvis confirmed the resolution of gastric intramural pneumatosis.

Although the patient tolerated solid food by hospital day 8, he remained hospitalized for continued IV antibiotics, close clinical monitoring due to comorbidities and recent sepsis, and to obtain follow-up imaging on day 15.

Here, we lend support to a conservative management strategy that involves discontinuing bowel rest based on the resolution of sepsis and severe symptoms. We also support re-imaging to ensure EG’s resolution before discontinuing antibiotics. One question not answered in this case was whether imaging could have been repeated when sepsis and severe symptoms resolved (when the diet was advanced) to see if gastric intramural pneumatosis had resolved and antibiotics could also have been stopped at that time. There is a need for further studies to help clarify these management decisions. Overall, this case demonstrates another successful treatment of EG utilizing a conservative approach in the hope that more standardized care guidelines can be developed for this highly fatal condition.