195

□ CASE REPORT □

Successful Conservative Treatment of EmphysematousGastritis

Yuichi Takano, Eiichi Yamamura, Kuniyo Gomi, Misako Tohata, Toshiyuki Endo,

Reika Suzuki, Masafumi Hayashi, Toru Nakanishi, Shotaro Hanamura,

Kunio Asonuma, Satoshi Ino, Yuichiro Kuroki, Naotaka Maruoka,

Masatsugu Nagahama, Kazuaki Inoue and Hiroshi Takahashi

Abstract

Emphysematous gastritis is an extremely rare disease with an unfavorable prognosis. To date, very few

studies have been conducted regarding the intragastric recovery process based on endoscopic findings. We

herein report a case of emphysematous gastritis that improved with long-term (five months) conservative

treatment in which we were able to observe the intragastric recovery process endoscopically. In cases in

which emphysematous gastritis is suspected, it is important to provide prompt diagnostic imaging (including

CT) and early appropriate treatment in order to improve the prognosis.

Key words: emphysematous gastritis, conservative treatment, endoscopic findings

(Intern Med 54: 195-198, 2015)(DOI: 10.2169/internalmedicine.54.3337)

Introduction

Emphysematous gastritis is an inflammatory disease char-

acterized by the presence of air within the stomach wall

caused by gas-producing bacteria. It has an extremely unfa-

vorable prognosis and is a very rare condition, with a search

of the English-language medical literature yielding only ap-

proximately 70 cases worldwide. Only a few such studies

have mentioned the intragastric recovery process based on

endoscopic findings. In the present study, we report a case

that improved with long-term conservative treatment in

which we were able to observe the intragastric recovery

process endoscopically.

Case Report

The patient was a 58-year-old man with a history of

chronic renal failure (under maintenance dialysis), type 2

diabetes and an old myocardial infarct. The patient pre-

sented to the emergency room with hematochezia requiring

endoscopic hemostasis to control bleeding from a rectal ul-

cer. He was hospitalized and showed satisfactory progress;

however, six days after admission, he complained of sudden

intense abdominal pain. An examination of his vital signs

indicated a blood pressure of 128/90 mmHg, heart rate of

118 beats per minute and temperature of 37.7°C. An ab-

dominal examination demonstrated intense pain upon pres-

sure in the epigastrium, with rebound tenderness, but no ab-

dominal guarding. Blood tests revealed a white blood cell

count of 19,260/μL and C-reactive protein level of 27.8 mg/

dL, indicating the presence of a marked inflammatory re-

sponse. Plain abdominal radiography (in the recumbent posi-

tion) revealed gas in the distended stomach (Fig. 1).

Plain and contrast-enhanced computed tomography (CT)

of the abdomen (Fig. 2-4) showed irregular, mottled gas in

the wall of the greater curvature of the stomach. No clear

evidence of thrombi was observed in the celiac or superior

mesenteric arteries; however, severe arteriosclerosis was

noted in the splenic artery. Based on these characteristic

findings, the patient was diagnosed with emphysematous

gastritis. Due to the fact that there were no signs of pan-

peritonitis or gastrointestinal perforation, such as ascites and

free air, a course of conservative treatment was selected.

Division of Gastroenterology, Showa University Fujigaoka Hospital, Japan

Received for publication May 21, 2014; Accepted for publication June 22, 2014

Correspondence to Dr. Yuichi Takano, yuichitakano1028@yahoo.co.jp

Intern Med 54: 195-198, 2015 DOI: 10.2169/internalmedicine.54.3337

196

Figure　1.　Plain abdominal radiograph showing gas in the distended stomach

Figure　2.　Plain computed tomography of the abdomen show-ing irregular, mottled gas in the wall of the greater curvature of the stomach, which is characteristic of emphysematous gas-tritis. A nasogastric tube is also evident in the stomach.

Figure　3.　Severe arteriosclerosis in the splenic artery Figure　4.　Contrast enhanced CT showing no clear evidence of thrombi in the celiac and superior mesenteric arteries

The treatment was implemented immediately, comprising

broad-spectrum antibiotics (meropenem 0.5 g/day × 14

days), proton pump inhibitors, a nasogastric tube, bowel rest

and central venous hyperalimentation. A bloody gastric juice

culture was positive for Escherichia coli and Enterococcusavium, both of which were sensitive to meropenem. Mean-

while, two sets of blood cultures were both negative.

Upper gastrointestinal endoscopy was performed one

month after symptom onset, when the patient’s general con-

dition had improved. The examination disclosed a large ul-

cer with purulent drainage that extended from the fundus to

the greater curvature of the gastric corpus (Fig. 5). Bowel

rest was therefore maintained for an additional two months,

and, thereafter, repeat endoscopy revealed a large amount of

necrotic tissue at the base of the ulcer (Fig. 6). The patient

attempted to resume oral intake on several occasions; how-

ever, as his fever and abdominal pain worsened, central ve-

nous hyperalimentation was continued as his only source of

nourishment for five months. Although enteral nutrition was

considered during the observation period, due to the large

size of the ulcer and the patient’s prolonged inflammation, it

was believed that the long-term placement of a feeding tube

would induce damage to the mucosa of the stomach wall

and/or exacerbate the infection. Therefore, we opted for cen-

tral venous hyperalimentation as the only source of nourish-

ment. We also repeatedly considered surgical treatment (total

gastrectomy or enterostomy) but were unable to obtain con-

sent from the patient and his family.

Repeat upper gastrointestinal endoscopy performed five

months after symptom onset demonstrated a marked im-

provement, with nearly complete epithelization of the ulcer

(Fig. 7). Abdominal CT also showed an improvement in the

stomach distension and the complete disappearance of the

interstitial emphysema in the stomach wall. The oral intake

of food was subsequently reinitiated, and the patient’s pro-

gress was satisfactory. Therefore, he was discharged from

the hospital six months after his initial presentation.

Emphysematous gastritis has an unfavorable prognosis

and is often fatal. This study reports an extremely rare case

in which an improvement was achieved with conservative

therapy and the recovery process was observed endoscopi-

cally.

Discussion

Emphysematous gastritis, first described by Fraenkel in

1889 (1), is a rare disease caused by gas-producing bacteria

Intern Med 54: 195-198, 2015 DOI: 10.2169/internalmedicine.54.3337

197

Figure　5.　Upper gastrointestinal endoscopy showing a large ulcer with purulent drainage in an area extending from the fundus to the greater curvature of the gastric corpus

Figure　6.　Upper gastrointestinal endoscopy performed two months after symptom onset showing a large amount of necrot-ic tissue at the base of the ulcer

Figure　7.　Upper gastrointestinal endoscopy performed five months after symptom onset showing a marked improvement, with nearly complete epithelization of the ulcer

and characterized by the presence of air within the stomach

wall with diffuse gastric wall inflammation. The prognosis

is extremely unfavorable, with a mortality rate of 55-

61% (2-4). The condition is associated with the ingestion of

corrosives, such as ammonia and acid, alcohol abuse, diabe-

tes, renal failure, gastroenteritis, recent abdominal surgery,

long-term steroid use, pancreatitis and nonsteroidal anti-

inflammatory drug use (5). In other words, it is believed that

emphysematous gastritis is triggered by factors such as phar-

maceuticals and ischemia that damage the gastric mucosal

barrier.

There is no established diagnostic standard for detecting

emphysematous gastritis. Previous studies have diagnosed

emphysematous gastritis based on the following four crite-

ria: 1. severe clinical symptoms such as abdominal pain, fe-

ver and vomiting, 2. marked elevation in the inflammatory

response, as observed on blood tests, 3. imaging findings in-

dicating intramural gastric emphysema (air within the stom-

ach wall), 4. evidence of bacterial infection, based on gastric

juice culture or pathology specimens. The present patient

met all four of these criteria.

In addition, the present patient suffered from both diabe-

tes and chronic renal failure, which is strongly suggestive of

arteriosclerosis and the possibility of ischemia. Furthermore,

abdominal CT showed severe arteriosclerosis in the splenic

artery. Branches of the splenic artery (left gastroepiploic ar-

tery and short gastric artery) supply blood to the greater cur-

vature of the stomach (6). Considering that, in this case, the

lesion was located in the greater curvature of the stomach,

we believe the underlying mechanism was as follows: ische-

mia in the splenic artery, which supplies the greater curva-

ture of the stomach, induced necrosis of the stomach wall,

subsequently leading to infection.

Furthermore, because a rectal ulcer was observed, we can-

not rule out the possibility of the hematogenous transmis-

sion of infection from the rectal ulcer to the stomach.

Patients with emphysematous gastritis usually present

with severe abdominal pain, nausea, vomiting, fever and oc-

casionally hematemesis (7). Physical findings include ab-

dominal distension and decreased bowel sounds. Affected

individuals may also display signs of peritoneal irritation.

The most frequently isolated organisms are streptococci,

E. coli, Enterobacter species, Pseudomonas aeruginosa and

Clostridium perfringens (8). Some studies have reported that

infection caused by fungi can occur in patients with emphy-

sematous gastritis, although this finding is rare (9).

CT is the most effective diagnostic imaging modality, as

it can be used to identify even small areas of interstitial em-

physema (3, 5). Plain abdominal radiography is useful for

imaging gas within the distended stomach as well as detect-

ing interstitial emphysema. Both modalities are therefore

helpful in making a diagnosis.

The main differential diagnoses for gas in the stomach

wall are emphysematous gastritis and gastric emphysema or

gastric pneumatosis (10, 11). It is important to differentiate

Intern Med 54: 195-198, 2015 DOI: 10.2169/internalmedicine.54.3337

198

emphysematous gastritis from gastric emphysema because

their clinical courses are completely different. In gastric em-

physema, gas is observed in the stomach wall without bacte-

rial infection; the condition is usually asymptomatic and re-

solves spontaneously without treatment. Studies have identi-

fied gastric outlet obstruction, excessive vomiting, nasogas-

tric tube placement, cardiopulmonary resuscitation and stom-

ach ulcers to be causative factors in such cases (11). Charac-

teristic CT findings of emphysematous gastritis include ir-

regular, mottled gas in the stomach wall, while gastric em-

physema is indicated by the presence of thin linear gas in

the stomach wall (5).

No consensus exists as to the optimal treatment strategy,

although a small number of studies have reported successful

results with conservative treatment in recent

years (7, 8, 12, 13). These reports focused on the use of

broad-spectrum antibiotics, bowel rest and nutritional man-

agement. Conservative treatment is considered a therapeutic

option in cases of emphysematous gastritis that do not pre-

sent with perforation or pan-peritonitis. However, surgery

should be considered in patients complicated with perfora-

tion, intestinal necrosis or peritonitis.

In comparison with that observed in other cases reported

in the medical literature, the present patient took an ex-

tremely long time to improve. This observation appears to

be due to the severity of the emphysematous gastritis and

the fact that the patient was undernourished.

The authors state that they have no Conflict of Interest (COI).

References

1. Fraenkel E. Ueber einen fall von gastritis acuta emphysematosa

wahrscheinlich mykotischen ursprungs. Arch Pathol Anat Physiol

Klin Med 118: 526-535, 1889.

2. Moosvi AR, Saravolatz LD, Wong DH, Simms SM. Emphysema-

tous gastritis: case report and review. Rev Infect Dis 12: 848-855,

1990.

3. van Mook WN, van der Geest S, Goessens ML, Schoon EJ, Ram-

say G. Gas within the wall of the stomach due to emphysematous

gastritis: case report and review. Eur J Gastroenterol Hepatol 14:

1155-1160, 2002.

4. Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysema-

tous infections of the abdomen and pelvis: a pictorial review. Ra-

diographics 22: 543-561, 2002.

5. Shipman PJ, Drury P. Emphysematous gastritis: case report and

literature review. Australas Radiol 45: 64-66, 2001.

6. Michels NA. Blood Supply and Anatomy of the Upper Abdominal

Organs with a Descriptive Atlas. Lippincott, Philadelphia, PA,

USA, 1955: 208-210.

7. Paul M, John S, Menon MC, Golewale NH, Weiss SL, Murthy

UK. Successful medical management of emphysematous gastritis

with concomitant portal venous air: a case report. J Med Case Rep

4: 140, 2010.

8. Szuchmacher M, Bedford T, Sukharamwala P, Nukala M, Parikh

N, Devito P. Is surgical intervention avoidable in cases of emphy-

sematous gastritis? A case presentation and literature review. Int J

Surg Case Rep 4: 456-459, 2013.

9. Jung JH, Choi HJ, Yoo J, Kang SJ, Lee KY. Emphysematous gas-

tritis associated with invasive gastric mucormycosis: a case report.

J Korean Med Sci 22: 923-927, 2007.

10. Bajaj M, Ogilvy-Stuart AL. Gastric pneumatosis/interstitial em-

physema of the stomach. Arch Dis Child Fetal Neonatal Ed 89:

F188, 2004.

11. Pauli EM, Tomasko JM, Jain V, Dye CE, Haluck RS. Multiply re-

current episodes of gastric emphysema. Case Rep Surg 2011:

587198, 2011.

12. Ocepek A, Skok P, Virag M, Kamenik B, Horvat M. Emphysema-

tous gastritis-case report and review of the literature. Z Gastroen-

terol 42: 735-738, 2004.

13. Arezzo A, Famiglietti F, Garabello D, Morino M. Complete reso-

lution of emphysematous gastritis after conservative management.

Clin Gastroenterol Hepatol 9: e30, 2011.

Ⓒ 2015 The Japanese Society of Internal Medicine

http://www.naika.or.jp/imonline/index.html