Redescending Stomach: A Rare and Potentially Lethal Complication of Gastric Herniation.

Large gastric hernias are common and usually cause minor symptoms. Rarely, complete intrathoracic herniation of the stomach is complicated by strangulation. The underlying mechanism can be gastric volvulus or the less recognized phenomenon of gastric fundus redescent. We describe a case where this rare but potentially lethal complication of gastric herniation is present. Additionally, we show that gastric pneumatosis, a sign associated with ischemia, can be initially visualized on a plain chest radiograph in this setting. Teaching point: Redescent of the fundus is a possible, but unrecognized cause of gastric strangulation in intrathoracic stomachs.

Ominous Sign of Pneumatosis Intestinalis With Portal Venous Gas.

The presence of gas and free air in the extraluminal space of the intestines is known as pneumatosis intestinalis (PI). There are many different causes of this finding, including gastrointestinal, pulmonary, autoimmune, and many more. It is often difficult to differentiate the etiology and clinical importance of the radiographic evidence on pneumatosis intestinalis due to the unclear pathophysiology causing the disease. To complicate things further, the ominous sign of portal venous gas poses the question of whether surgical intervention is needed. We report two cases both with clinical and radiographic evidence of secondary pneumatosis intestinalis with an associated sinister finding of portal venous gas. The cases differ by urgent surgical intervention versus observation before surgery. In this case series, we emphasize the importance of recognizing the radiographic finding and stress the need for further research to standardize a plan of care, including indications for surgery. We encourage more cases like this to be reported to aid in diagnosing and treating this condition early on with the aim of improving the mortality associated with it.

Gastric pneumatosis in immunocompromised patients: A report of 2 cases and comprehensive literature review.

Gastric pneumatosis (GP) is a rare finding. It can be seen with both gastric emphysema (GE) and emphysematous gastritis (EG); however, both conditions present similarly and differentiating between the 2 is difficult radiographically. Moreover, the treatment is vastly different for both conditions, in which treatment for GE is focused on supportive care while treatment for EG may even involve gastrectomy. Making the distinction between GE and EG is crucial because GE has a benign clinical course, while EG carries significant mortality. Early endoscopy may be a useful tool in differentiating between the 2 conditions and to guide further management. Herein, we present a case series of 2 immunocompromised patients who presented with symptoms and radiographic evidence consistent with gastric pneumatosis. We found that early endoscopy assisted in risk stratification and helped guide our management strategy. We recommend consideration of endoscopic evaluation as part of ritualized evaluation of patients presenting with gastric pneumatosis.

Gastric Ischemia after SARS-CoV-2 Infection.

Gastric ischemia is uncommon because the stomach has multiple collateral blood supplies. The etiology of gastric ischemia is vascular insufficiency caused by systemic hypotension, vasculitis, or disseminated thromboembolism. Mechanical causes include gastric volvulus and acute gastric distention. Uncommon as gastric ischemia is, we are the first to report a 65-year-old male who developed gastric ischemia leading to gastric pneumatosis 26 days after initial treatment for severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2), via laparoscopic imaging. We conclude that physicians should be suspicious of gastric ischemia when the patient is infected with SARS-CoV-2 with severe abdominal pain and should proceed with medical conservative care instead of surgery.

A Case Report on Hepatic Portal Venous Gas (HPVG).

Hepatic Portal Venous Gas (HPVG) is the abnormal presence of gas in the portal venous system. It is associated with life-threatening conditions and is a sinister radiological sign. This case report aims to evaluate the significance of HPVG as a radiological sign. Our case involves a 49-year-old man who was admitted to the hospital following a one-day history of severe epigastric pain and haematemesis. Investigations showed extensive HPVG, gastric pneumatosis, a large retroperitoneal haematoma, and an obstructive lesion between the first and second part of the duodenum. Our patient was managed conservatively in the High Dependency Unit (HDU). A repeat Computerised Tomography (CT) scan showed successful resolution of the HPVG and gastric pneumatosis without any invasive intervention.

Conservative Management of Suspected Emphysematous Gastritis.

Emphysematous gastritis is a rare surgical condition. Although there is a lack of a common definition, the key features of its presentation include gastric emphysema on imaging and the presence of gas-forming organisms in the gastric mucosa. In this study, we report the case of an 80-year-old Caucasian male who presented with abdominal pain; a computed tomography scan demonstrated gastric emphysema (intra-mural air within the stomach). After upper gastrointestinal endoscopy excluded gross perforation, ulcer, and malignancy, the patient recovered to baseline with conservative management consisting of gastric rest (nil by mouth and nasogastric tube decompression), intravenous antibiotics, and intravenous proton pump inhibitor. Given the wide pathogenic mechanisms for gastric emphysema, we recommend a conservative but cautious approach if the patient does not demonstrate clinical features of hemodynamic instability, sepsis, and peritonitis.

Gastric pneumatosis and concurrent aeroportia due to gastric outlet obstruction: A case report.

INTRODUCTION AND IMPORTANCE: Gastric pneumatosis with concurrent hepatic portal vein gas is an extremely rare condition in the adult population. It can be idiopathic or associated with well-known etiologies. Gastric outlet obstruction can progressively inflate the stomach and cause pneumatosis. Regarding abdominal signs and the presence of acute abdomen, management varies from just conservative to emergent surgical interventions. CASE PRESENTATION: We introduce an adult patient who presented to our hospital with weakness and dyspnea. After initial measures, unexpectedly we found intraabdominal free gas, concurrent gastric pneumatosis, and aeroportia. Due to the absence of positive abdominal signs, the patient was treated successfully without any surgical or endoscopic interventions. DISCUSSION: Gastric outlet obstruction is a well-known cause of gastric pneumatosis. Progressive dilation of the stomach due to pyloric stenosis is well-described both in infants and adult populations. CONCLUSION: In stable patients, gastric drainage and correction of electrolyte disturbance are the only required treatment. However endoscopic and surgical interventions should be considered in unstable patients or those developing acute abdomen.

Case report: gastric ischemia, a fatal disease of gastric pneumatosis.

BACKGROUND: Gastric pneumatosis indicates the presence of air within the stomach wall. The etiologies included gastric ischemia, gastric intramural infection, gastric mucosal disruption, and secondary to pneumomediastinum. Gastric ischemia is rare because of the rich collateral blood supply to the stomach. CASE PRESENTATION: An 82-year-old man presented to the emergency department with a 2-day history of epigastric fullness, following by fever and low blood pressure. Chest X-ray and abdominal computed tomography revealed gastric pneumatosis at the gastric fundus. The esophagogastroduodenoscopy confirmed the ischemic change of mucosa at the gastric fundus. After antibiotics and medical management, the patient became better and was eventually discharged. CONCLUSION: For the diagnosis of gastric ischemia, physicians should be alert to the hints of gastric pneumatosis from X-ray and computed tomography. It is important to distinguish between gastric ischemia and the other causes of gastric pneumatosis to judge clinical management.

Gastric pneumatosis in a patient with anorexia nervosa.

Gastric pneumatosis can be caused by mechanical force, pulmonary disease, bacterial infection, and ischemic condition. It can be managed conservatively, however, according to the etiology, surgery may be required.

Gastritis enfisematosa como manifestación de isquemia mesentérica no oclusiva tras coartectomía / Emphysematous gastritis as a manifestation of non-occlusive mesenteric ischemia after coartectomy

Resumen Las intervenciones mayores en cirugía cardiovascular de pacientes con patología aórtica pueden traer como consecuencia el compromiso de la perfusión de órganos distantes al sitio de la cirugía, siendo el tracto gastrointestinal uno de los más sensibles a los cambios hemodinámicos, en especial en grupos extremos de edad con un alto riesgo de morbimortalidad. Se reporta el caso de una lactante con antecedente de síndrome de Turner, quien es llevada a corrección de coartación de aorta más hipoplasia del arco, presentando como complicación posoperatoria un cuadro de gastritis enfisematosa con compromiso sistémico, proceso que fue favorecido por bajo gasto cardiaco posterior a bomba y presencia de urosepsis temprana, todo lo cual fue interpretado como parte del espectro del síndrome de isquemia mesentérica no oclusiva. Su diagnóstico precoz hizo posible una pronta intervención, consistente en soporte nutricional parenteral, freno ácido, antibioticoterapia de amplio espectro y seguimiento radiológico estricto, logrando la resolución completa de su sintomatología, sin complicaciones a corto plazo. Este caso demuestra que la identificación de factores de riesgo de isquemia esplácnica, una alta sospecha clínica y un cuidadoso manejo médico permiten un desenlace favorable para una patología con una alta tasa de mortalidad y muy pocos casos reportados en población pediátrica.

Abstract Major interventions in cardiovascular surgery of patients with aortic pathology can result in the compromise of perfusion of organs distant from the surgery site, the gastrointestinal tract being one of the most sensitive to hemodynamic changes, especially in extreme age groups with a high risk of morbidity and mortality. The case of a young infant is reported, with a history of Turner syndrome, who is led to correction of aortic coarctation plus arch hypoplasia, presenting as a postoperative complication a picture of emphysematous gastritis with systemic compromise, a process that was favored by low cardiac output post-pump and the presence of early urosepsis, all of which was interpreted as part of the spectrum of non-occlusive mesenteric ischemia syndrome. Its early diagnosis made possible a prompt intervention consisting of parenteral nutritional support, acid brake, broad-spectrum antibiotic therapy and strict radiological follow-up, achieving complete resolution of her symptoms, without short-term complications. This case demonstrated that the identification of risk factors for splanchnic ischemia, a high clinical suspicion and careful medical management, allowed a favorable outcome for a disease with a high mortality rate and very few cases reported in the pediatric population.

A Case of Gastric Emphysema: Incidental Findings or Serious Illness.

Gastric emphysema (GE) or gastric pneumatosis is a rare entity defined as air within the gastric wall. Etiologies include pneumothorax, instrumentation, infection, gastric wall ischemia, and mechanical injury. Several theories exist as to how the air disrupts the integrity of the gastric wall. These include a bacterial infection with Clostridium species and other gas-forming aerobic colonic bacilli, instrumentation with direct submucosal gastric wall injury, mechanical injury following increased intra-abdominal pressure, penetrating air through the mediastinum from increased intrapulmonary pressure or, gastric wall ischemia, which may be secondary to an underlying process. The diagnostic test of choice is CT of the abdomen. A hypodense linear fringe on the gastric wall is seen in GE, associated with gastric distention without thickening. In emphysematous gastritis, there is gastric wall thickening. There are no standardized guidelines for GE, but most cases have a good prognosis with a spontaneous resolution with conservation treatment. However, emphysematous gastritis management requires aggressive treatment due to the mortality rate of emphysematous gastritis approaching 60%. Patients are often considered for surgical intervention with total gastrectomy, given that active infection could delay or prevent healing. It is imperative to differentiate GE and emphysematous gastritis and understand the underlying pathogenesis as clinical outcomes are vastly different.

Emphysematous gastritis as a manifestation of non-occlusive mesenteric ischemia after coartectomy / Gastritis enfisematosa como manifestación de isquemia mesentérica no oclusiva tras coartectomía

Major interventions in cardiovascular surgery of patients with aortic pathology can result in the compromise of perfusion of organs distant from the surgery site, the gastrointestinal tract being one of the most sensitive to hemodynamic changes, especially in extreme age groups with a high risk of morbidity and mortality. The case of a young infant is reported, with a history of Turner syndrome, who is led to correction of aortic coarctation plus arch hypoplasia, presenting as a postoperative complication a picture of emphysematous gastritis with systemic compromise, a process that was favored by low cardiac output post-pump and the presence of early urosepsis, all of which was interpreted as part of the spectrum of non-occlusive mesenteric ischemia syndrome. Its early diagnosis made possible a prompt intervention consisting of parenteral nutritional support, acid brake, broad-spectrum antibiotic therapy and strict radiological follow-up, achieving complete resolution of her symptoms, without short-term complications. This case demonstrated that the identification of risk factors for splanchnic ischemia, a high clinical suspicion and careful medical management, allowed a favorable outcome for a disease with a high mortality rate and very few cases reported in the pediatric population.

Las intervenciones mayores en cirugía cardiovascular de pacientes con patología aórtica pueden traer como consecuencia el compromiso de la perfusión de órganos distantes al sitio de la cirugía, siendo el tracto gastrointestinal uno de los más sensibles a los cambios hemodinámicos, en especial en grupos extremos de edad con un alto riesgo de morbimortalidad. Se reporta el caso de una lactante con antecedente de síndrome de Turner, quien es llevada a corrección de coartación de aorta más hipoplasia del arco, presentando como complicación posoperatoria un cuadro de gastritis enfisematosa con compromiso sistémico, proceso que fue favorecido por bajo gasto cardiaco posterior a bomba y presencia de urosepsis temprana, todo lo cual fue interpretado como parte del espectro del síndrome de isquemia mesentérica no oclusiva. Su diagnóstico precoz hizo posible una pronta intervención, consistente en soporte nutricional parenteral, freno ácido, antibioticoterapia de amplio espectro y seguimiento radiológico estricto, logrando la resolución completa de su sintomatología, sin complicaciones a corto plazo. Este caso demuestra que la identificación de factores de riesgo de isquemia esplácnica, una alta sospecha clínica y un cuidadoso manejo médico permiten un desenlace favorable para una patología con una alta tasa de mortalidad y muy pocos casos reportados en población pediátrica.

Intramural gastric air in an acutely ill patient with endoscopic and surgical correlation.

Intramural gastric air is a rare but potentially life-threatening imaging finding. We present the case of a 56-year-old female patient with a history of schizophrenia, who presented with multiple episodes of vomiting and altered mental status. CT scan revealed intramural gastric air and portal venous gas. The patient was treated conservatively with a favorable outcome. Gastric emphysema and emphysematous gastritis should be considered in the differential diagnosis of air in the gastric wall. It is critical to distinguish between these 2 entities as their clinical course and management differ significantly, although radiographic findings may mimic each other.

Radiography and ultrasonography of pneumatosis intestinalis in a cat.

An adult cat was presented for acute history of vomiting and collapse. Radiographs showed the presence of air within small intestinal walls and arborizing gas patterns within the liver, compatible with pneumatosis intestinalis and presumed portal venous gas, respectively. An abdominal ultrasound the following day was suggestive of gas within the intestinal wall, however, gas within the hepatic vasculature, parenchyma, or biliary tree was not evident. Due to progressive clinical deterioration of the patient, the owners elected humane euthanasia. Necropsy revealed severe necrotizing hemorrhagic enterotyphlocolitis secondary to Clostridium difficile toxin.

Canine and feline emphysematous gastritis may be differentiated from gastric emphysema based on clinical and imaging characteristics: Five cases.

Gastric pneumatosis is an imaging finding defined as the presence of gas foci in the gastric wall. In humans, this imaging feature can result from one of two separate clinical entities: life-threatening emphysematous gastritis or clinically benign gastric emphysema. This retrospective case series study describes the clinical and imaging features in five animals diagnosed with spontaneous gastric pneumatosis without gastric dilatation-volvulus. Three canine and two feline cases of spontaneous gastric pneumatosis were identified on radiographic and ultrasonographic examinations. In addition to gastric pneumatosis, one dog and two cats presented concomitant systemic signs such as lethargy, hematemesis, anemia, or leukocytosis. Two dogs remained asymptomatic or presented mild gastrointestinal signs. Portal gas was described in two dogs and one cat, and pneumoperitoneum in one dog. These features were not considered clinically significant. The dog and two cats with systemic signs were euthanized due to clinical deterioration and diagnosed with emphysematous gastritis. The gastric pneumatosis of both dogs without systemic signs resolved while on medical management without antibiotic therapy. These latter cases were interpreted as consistent with gastric emphysema. Findings from the current study indicated that gastric pneumatosis can occur without gastric dilatation-volvulus in cats and dogs and that a combination of clinical and imaging characteristics may help to differentiate between potentially life-threatening emphysematous gastritis and relatively benign gastric emphysema. More studies are needed to determine the etiology and risk factors associated with these conditions.

Emphysematous gastritis in a cat.

OBJECTIVE: To describe the presentation, diagnosis, treatment, and outcome of a case of emphysematous gastritis (EG) in a cat. CASE SERIES SUMMARY: A 15-year-old female neutered domestic short-hair cat presented for a 4-month history of weight loss and intermittent vomiting. Clinicopathologic and imaging findings suggested an underlying primary gastrointestinal (GI) disease, as well as possible hepatobiliary disease. Two days following exploratory laparotomy to obtain GI and liver biopsies, the patient became septic and intracellular bacteria were present on cytology of peritoneal effusion. On radiographs, the stomach was markedly distended with fluid and contained a thin gas opacity surrounding the stomach wall. The patient was taken back to surgery to identify a source of sepsis. At surgery, the patient's stomach was firm and emphysematous on palpation but grossly appeared normal. There were no signs of dehiscence of the previous biopsy sites. Stomach biopsy confirmed the presence of intralesional Gram-positive rods, consistent with microbial EG, and a light growth of a Clostridium sp. was cultured from abdominal fluid, consistent with clostridial peritonitis. During a third surgery for suspected septic peritonitis, a jejunostomy tube was placed for postgastric enteral feeding. The patient ultimately survived to discharge and is clinically stable 10 months later. NEW/UNIQUE INFORMATION PROVIDED: EG is a rare but potentially fatal clinical entity in the human and veterinary literature with only 1 other case reported in cats. Though clostridial organisms have been reported in EG in people, this is the first implication of EG secondary to a Clostridium sp. in the cat. This is also the first report to document the use of a jejunostomy tube for postgastric enteral nutrition to treat EG in the veterinary literature.

Pneumatosis of the esophagus and intestines with portal venous air: a rare presentation.

Pneumatosis intestinalis is a radiographic finding that represents a spectrum of conditions ranging from benign disease to abdominal sepsis and death. Along with portal venous gas, it is generally considered an ominous sign prompting emergency operative intervention. We report a rare case showing that nonoperative therapy can be considered in a seriously ill patient with esophageal, gastric and portal venous air.

Air in the gastric wall of a patient with AIDS.

Emphysematous gastritis is a rare infection of the gastric wall with 55%-60% mortality. A 44-year-old man with AIDS, hepatitis C, and intravenous drug use presented with a 1-day history of acute-onset abdominal pain, nausea, and nonbloody, nonbilious emesis. On examination, he was afebrile without other vital sign abnormalities. He had epigastric abdominal tenderness without rebound or guarding. The peripheral-blood leukocyte count was elevated to 12.8 with 93.8% neutrophils. The patient's clinical presentation markedly improved with IV fluids and broad-spectrum antibiotic therapy. His presentation and radiologic findings, including gastric intramural air and air in the portal vein, are consistent with emphysematous gastritis. Conservative management is first-line for milder cases of emphysematous gastritis. Exploratory laparotomy and total gastrectomy are indicated only in severe cases such as transmural ischemia and peritonitis. Immune-compromised status is a predisposing factor and associated with subtler findings than the classic dramatic clinical presentation.