case report multiplyrecurrentepisodesofgastricemphysema · 2019. 7. 31. · medicine, hershey, pa...

Hindawi Publishing CorporationCase Reports in SurgeryVolume 2011, Article ID 587198, 3 pagesdoi:10.1155/2011/587198

Case Report

Multiply Recurrent Episodes of Gastric Emphysema

Eric M. Pauli,1 Jonathan M. Tomasko,1 Vishal Jain,2 Charles E. Dye,2 and Randy S. Haluck1

1 Division of Minimally Invasive and Bariatric Surgery, Penn State Hershey Milton S. Medical Center and Penn State College ofMedicine, Hershey, PA 17033, USA

2 Department of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine,Hershey, PA 17033, USA

Correspondence should be addressed to Eric M. Pauli, [email protected]

Received 7 June 2011; Accepted 7 August 2011

Academic Editor: T. Çolak

Copyright © 2011 Eric M. Pauli et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction. Gastric emphysema can present both a diagnostic challenge and a life-threatening condition for patients and has onlyonce been reported as being recurrent. Background. A 64-year-old male presented with chronic abdominal pain and was found tohave gastric pneumatosis on CT scan. The patient was successfully managed conservatively. The cause was attributed to aberrantarterial anatomy and atherosclerosis along with hypotension. The patient has since had 3 episodes of recurrent gastric emphysema,all managed nonoperatively. Discussion. To our knowledge, this is the first case of both serial episodes of gastric pneumatosis andgastric mucosal ischemia as a precipitating factor for the development of gastric emphysema.

1. Background

First described by Franekel in 1889, gastric emphysema con-tinues to represent an unusual cause of portal venous air inboth children and adults [1]. Clinicians must be able to dis-tinguish this benign condition, in which air dissects belowthe mucosa from a luminal source, from emphysematousgastritis, which is caused by a gas-forming bacterial infectionand which has a mortality rate as high as 70% [2, 3]. General-ly isolated and self-limited, gastric emphysema has only oncebeen reported to be recurrent [4]. Here, we present theclinical, endoscopic, and radiographic findings in a patientwith multiple bouts of gastric emphysema.

A 64-year-old male with a history of pancreatitis andchronic abdominal pain presented to his community hospitalwith worsening abdominal pain and hematemesis. Com-puted tomography (CT) showed diffuse gastric pneumatosisand portal venous air. He was urgently transferred to atertiary hospital with hypotension and abdominal pain outof proportion to exam findings. Due to a concern for gastricischemia, he underwent diagnostic laparoscopy; however, hisstomach appeared grossly normal. Intraoperative upper en-doscopy (EGD) was performed, which showed diffuse edemaand mucosal ischemia of the proximal 50% of the stomach(Figure 1).

The patient was managed with proton-pump inhibitor(PPI) therapy and bowel rest. Repeat EGD on hospital dayfive showed resolution of ischemia. Gastric biopsies wouldlater show no pathologic alteration. The patient’s pain re-solved and he was subsequently discharged.

The patient returned five days later with recurrent ab-dominal pain, hematemesis, and intermittent episodes ofhypotension. Bowel rest and intravenous PPIs were rein-stituted. CT scan showed worsening portal venous air andgastric pneumatosis (Figure 2). Repeat EGD demonstratedonly mild gastric mucosal ischemia. Mesenteric angiographywas performed and showed atherosclerosis and an aberrantleft gastric artery, with its origin above the diaphragmaticcrus (Figure 3). There was no flow limiting stenosis. He wasstarted on antiplatelet and statin therapy.

He since has had an additional recurrence of gastricpneumatosis and portal venous air, which was again man-aged conservatively.

2. Discussion

In this case, we suspect that mesenteric atherosclerotic dis-ease, aberrant left gastric arterial anatomy, dyslipidemia, andintermittent bouts of hypotension all contributed to a syn-drome of intermittent mesenteric flow insufficiency resulting

2 Case Reports in Surgery

Figure 1: Endoscopic view of the stomach body demonstratingpatchy areas of ischemia.

Figure 2: Axial CT scan image demonstrating portal venous gas(arrows) and gastric emphysema (arrowheads). Several benign hep-atic cysts are also visualized.

in mucosal ischemic ulceration, gastric emphysema, and por-tal vein gas. The patient’s pain-induced vomiting may havebeen a contributing factor in the development of his recur-rent episodes of pneumatosis.

Main causes of benign gastric pneumatosis are varied andinclude gastric outlet obstruction, excessive vomiting, place-ment of a nasogastric tube, CPR, and ulcer disease [5].Additional unusual sources of portal venous gas have beendescribed. Zenooz et al. described colonic ischemia as a po-tential source of portal venous gas, which resolved aftercolectomy [6]. Blunt abdominal trauma has also been impli-cated as an uncommon source of gastric pneumatosis, whichhas been successfully managed nonoperatively with repeatimaging and endoscopy to confirm resolution [7]. Prior tothis, aggressive celiotomy and gastric resection had been ad-vocated [8].

To our knowledge, this is the first reported case of bothserial episodes of gastric pneumatosis (>2) and gastric mu-cosal ischemia as a precipitating factor for the developmentof gastric emphysema. Interestingly, nonocclusive mesentericdisease has been associated with the development of portalvenous gas in the setting of ischemia [9]. In addition, idio-pathic gastric pneumatosis has also been described with asole presenting symptom of pain by Barbour et al. [10] for

Figure 3: Sagittal CT scan image demonstrating the supra-dia-phragmatic origin of the left gastric artery (arrow) and the separateceliac origin (arrowhead). Aortic atherosclerotic calcifications canalso be seen.

which an extensive workup only yielded minor celiac arteryartherosclerotic disease as a possible culprit. This patient iscurrently undergoing evaluation by vascular medicine andvascular surgical services.

Chronic ischemic gastritis is an unusual entity with a fre-quently delayed diagnosis, likely from the nonspecific symp-toms, inadequate histopathology, and a generalized beliefthat the stomach has a robust arterial blood supply that pro-tects it from ischemia [11]. This case demonstrates the dili-gence necessary to make this rare diagnosis and adds ischem-ic gastritis to the differential diagnosis of gastric emphysemaand demonstrates under select circumstances the ability tomanage this entity nonoperatively.

Disclosure

The authors have no relevant disclosures for the preparationof this paper.

References

[1] E. Franekel, “Üeber einen Fall von Gastritis acuta emphy-sematosa wahrscheinlich mykotishen Ursprungs,” VirchowsArchiv, vol. 118, no. 3, pp. 526–535, 1889.

[2] N. R. Cordum, A. Dixon, and D. R. Campbell, “Gastrodu-odenal pneumatosis: endoscopic and histological findings,”American Journal of Gastroenterology, vol. 92, no. 4, pp. 692–695, 1997.

[3] D. R. Taylor, J. Y. Tung, J. M. Baffa, S. E. Shaffer, and U. Blecker,“Gastric pneumatosis: a case report and review of the litera-ture,” International Pediatrics, vol. 15, no. 2, pp. 117–120, 2000.

[4] M. Kalina and M. Rubino, “Recurrent gastric emphysema,”The American Surgeon, vol. 75, no. 11, pp. 1149–1151, 2009.

[5] I. Nault and C. Lauzon, “Gas in the portomesenteric vesselsfrom nonocclusive ischemic bowel disease,” CMAJ, vol. 176,no. 3, pp. 321–323, 2007.

[6] N. A. Zenooz, M. R. Robbin, and V. Perez, “Gastric pneumato-sis following nasogastric tube placement: a case report withliterature review,” Emergency Radiology, vol. 13, no. 4, pp. 205–207, 2007.

Case Reports in Surgery 3

[7] S. F. Millward and M. Fortier, “Transient gastric emphysemacaused by colonic infraction,” American Journal of Roentgenol-ogy, vol. 176, no. 5, pp. 1331–1332, 2001.

[8] M. Scaglione, F. Lassandro, F. Pinto et al., “Gastric pneumato-sis and portal vein gas: incidental findings at helical CT afterblunt abdominal trauma,” Emergency Radiology, vol. 8, no. 3,pp. 162–164, 2001.

[9] D. D. Kingsley, R. M. Albrecht, and D. M. Vogt, “Gastric pneu-matosis and hepatoportal venous gas in blunt trauma: clinicalsignificance in a case report,” The Journal of Trauma, vol. 49,no. 5, pp. 951–953, 2000.

[10] J. R. Barbour, J. P. Stokes, A. Uflacker, S. B. Saunders, and K. A.Morgan, “Spontaneous gastric pneumatosis causing abdomi-nal pain,” The American Surgeon, vol. 76, no. 2, pp. 220–222,2010.

[11] V. Quentin, N. Dib, F. Thouveny, P. L’Hoste, A. Croue, andJ. Boyer, “Chronic ischemic gastritis: case report of a difficultdiagnosis and review of the literature,” Endoscopy, vol. 38, no.5, pp. 529–532, 2006.

Submit your manuscripts athttp://www.hindawi.com

Stem CellsInternational

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014

Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

case report multiplyrecurrentepisodesofgastricemphysema · 2019. 7. 31. · medicine, hershey, pa...

Documents