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Emphysematous Gastritis Associated with Gastric Infarction in a Patient with Adult Polycystic Renal Disease

CT Diagnosis

Prince of Wales Hospital Chinese University of Hong Kong Shatin, New Territories, Hong Kong

Emphysematous gastritis is a rare but severe form of widespread phlegmonous gastritis. It is caused by mucosal disruption characterized by gas in the stomach wall. The most common cause of emphysematous gastritis is corrosive ingestion. Other causes include trauma or gastric infarction.

A 53-year-old man with a known history of adult polycystic renal disease was admitted to our institution so that the cause of his attacks of diarrhea could be determined. His condition was complicated by the presence of end-stage renal failure and tertiary hyperparathyroidism for which he was undergoing continuous ambulatory peritoneal dialysis. During the second week of hospitalization, the patient had a minor stroke and non-Q acute myocardial infarction. During the third week, the patient's condition suddenly deteriorated: He began running a high fever and experienced septic shock that required admission to the ICU. The patient's WBC was elevated to 34.2. At physical examination, he was found to have cold extremities, gangrene of the right arm and fingers, and a distended abdomen.

Emergency contrast-enhanced CT of the abdomen and pelvis showed evidence of polycystic disease with liver and renal involvement. Extensive vascular calcification was present, consistent with hyperparathyroidism (Fig. 1A), and multiple fluid-filled distended loops of small bowel were seen. Irregular, mottled gas was observed in the wall of the stomach, along with thickened folds consistent with emphysematous gastritis (Fig. 1B). No portal venous gas was evident. A rim of subcapsular contrast enhancement of the spleen, suggestive of splenic infarction (Fig. 1C), was visible. The patient underwent emergency upper gastrointestinal endoscopy, which confirmed that the stomach was gangrenous. In view of his poor general condition, the patient was not considered for emergency laparotomy and died the next day.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —53-year old man with adult polycystic disease complicated by end-stage renal failure and tertiary hyperparathyroidism admitted to ICU for treatment of septic shock. Unenhanced CT scan shows multiple cysts—some with calcified walls—in both kidneys, a finding that is in keeping with adult polycystic disease. Extensive abdominal vascular calcification consistent with tertiary hyperparathyroidism is also visible.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —53-year old man with adult polycystic disease complicated by end-stage renal failure and tertiary hyperparathyroidism admitted to ICU for treatment of septic shock. Contrast-enhanced CT scan shows irregular, mottled gas (arrow) in stomach wall.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —53-year old man with adult polycystic disease complicated by end-stage renal failure and tertiary hyperparathyroidism admitted to ICU for treatment of septic shock. Contrast-enhanced CT scan shows subcapsular enhancement (arrows) of spleen, suggestive of splenic infarction.

The main differential diagnosis for intramural gas is emphysematous gastritis, interstitial gastritis, and pneumatosis cystoides. In the case of pneumatosis cystoides, the patient is usually asymptomatic clinically. In patients with interstitial gastritis, the appearance of intramural gas tends to be sharply defined and linear. Some patients may have recently undergone a gastric procedure [1, 2].

Emphysematous gastritis is an almost uniformly fatal disease. Surgical intervention after development of emphysematous gastritis has been unsuccessful. A protocol of early treatment with a broad-spectrum antibiotic and surgical revascularization performed immediately after diagnostic angiography has been reported to successfully reverse gastric ischemia [3].

References

1. Monteferrante M, Shimkin P. CT diagnosis of emphysematous gastritis. AJR 1989;153:191 -192[Medline]
2. Sud A, Lehl SS, Bhasin DK, Deodhar SD. Emphysematous gastritis. Am J Gastroenterol 1996;91:604 -605[Medline]
3. Binmoeller KF, Benner KG. Emphysematous gastritis secondary to gastric infarction. Am J Gastroenterol 1992;87:526 -529[Medline]

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				ANSWER Gut, September 1, 2008; 57(9): 1314 - 1314. [Full Text] [PDF]

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wong, Y. Y. Articles by Chu, W. C. W. Search for Related Content PubMed PubMed Citation Articles by Wong, Y. Y. Articles by Chu, W. C. W. Social Bookmarking                      What's this?