ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—STOMACH
A Rare Diagnosis with a Rare Etiology: A Case of Retching-Induced Gastric Emphysema
Introduction: Gastric pneumatosis refers to the presence of air within the wall of the stomach. Intramural gastric air is a rare clinical condition. It was first described by Brouardel in 1895. It can be classified into two types: gastric emphysema (GE) and emphysematous gastritis. GE is essentially non-life threatening and can be caused by a variety of iatrogenic and noniatrogenic events. Pulmonary, trauma, and obstruction are the three principal theories proposed to explain its pathogenesis. They have a benign clinical course and patients often have uneventful recovery with conservative treatment. We hereby present a case of GE induced by retching where patient was successfully managed by conservative measures. Case Presentation: 42 years old lady known to have Type II DM, Hypertension, Ischemic Cardiomyopathy Status post Implantable cardioverter defibrillator, Chronic Migraine and history of deep venous thrombosis and pulmonary embolism presented with nausea and abdominal pain of one day duration. She described the pain as epigastric and sharp that started after repeated episodes of retching. She denied having any fever, chills, and change in bowel or bladder habits. Her physical exam was remarkable for epigastric tenderness. Her labs in emergency room were significant for elevated white cell count of 14860/ uL. Her lactate was 2.6. She underwent CT scan of the abdomen which showed intramural air in body and the fundus. She was made NPO and started on IV antibiotics. She underwent EGD that revealed a small Mallory-Weiss tear and diffuse gastric erythema with underlying small submucosal hemorrhage. After ruling out emphysematous gastritis, subsequently the IV antibiotics were stopped and slowly oral feeding was resumed. Her abdominal pain and nausea improved and she was discharged home in a stable condition.Conclusions: Intramural gastric air is usually a diagnostic dilemma. Emphysematous Gastritis and GE remain two important differential diagnoses of intramural gastric air. They differ in their clinical presentation, radiographic findings, management and prognosis. It is therefore essential to treat aggressively initially until emphysematous gastritis is ruled out which has a fulminant course as we did in our case. Another differentiating pattern that can help in diagnoses is the air pattern. Streaky or linear air pattern is suggestive of GE and mottled or bubbly appearance is suggestive of Emphysematous gastritis.© The American College of Gastroenterology 2018. All Rights Reserved.