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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
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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
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emphy-sematosa wahrscheinlich mykotishen Ursprungs,”
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Case Reports in Surgery 3
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[10] J. R. Barbour, J. P. Stokes, A. Uflacker, S. B. Saunders,
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[11] V. Quentin, N. Dib, F. Thouveny, P. L’Hoste, A. Croue,
andJ. Boyer, “Chronic ischemic gastritis: case report of a
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