What is the treatment for emphysematous gastritis?

Treatment of Emphysematous Gastritis

The treatment of emphysematous gastritis should include aggressive medical management with broad-spectrum antibiotics targeting gas-forming organisms, nothing by mouth (NPO status), intravenous fluid resuscitation, and proton pump inhibitors, with surgery reserved only for cases with clinical deterioration or signs of peritonitis. 1, 2

Pathophysiology and Diagnosis

Emphysematous gastritis (EG) is a rare and potentially fatal condition characterized by:

• Gas within the gastric wall due to invasion by gas-forming microorganisms
• Common causative organisms include gram-negative bacteria and anaerobes
• Predisposing factors: corrosive ingestion, alcohol abuse, recent abdominal surgery, cancer, immunosuppression, and diabetes 2, 3, 4

Diagnosis is primarily established by:

• CT scan showing intramural air in the stomach wall (diagnostic gold standard)
• Clinical presentation of abdominal pain with signs of systemic toxicity
• Laboratory findings showing elevated inflammatory markers 2, 5

Treatment Algorithm

First-Line Management (Conservative Approach)

1. Antimicrobial Therapy

   • Broad-spectrum antibiotics covering gram-negative organisms and anaerobes 1, 4
   • Treatment duration of 7-14 days, adjusted based on clinical response 1

2. Supportive Care

   • Nothing by mouth (NPO status)
   • Intravenous fluid resuscitation
   • Proton pump inhibitor therapy
   • Nutritional support (parenteral nutrition initially) 2, 5

3. Monitoring

   • Close clinical monitoring for signs of deterioration
   • Follow-up CT scan in 3-4 days to assess resolution of pneumatosis 2

Indications for Surgical Intervention

• Failure to respond to conservative management
• Clinical deterioration despite appropriate medical therapy
• Development of peritonitis
• Evidence of gastric necrosis or perforation 2

Special Considerations

• The presence of portal venous air or pneumoperitoneum alone should not be considered an absolute indication for surgical exploration 2
• Early recognition and prompt initiation of appropriate therapy is crucial to prevent progression and reduce mortality 6, 5
• Underlying conditions (such as gastric cancer) should be investigated and managed appropriately once the acute phase has resolved 3
• Mortality rates remain high despite advances in medical science, emphasizing the importance of aggressive early management 6

Follow-up

• Repeat CT scan to confirm resolution of gastric pneumatosis
• Gradual reintroduction of oral diet once clinical improvement is observed and repeat imaging shows resolution
• Investigation for underlying predisposing factors if not already identified 2, 5

Pitfalls to Avoid

• Delaying antibiotic therapy while awaiting culture results
• Premature surgical intervention without a trial of conservative management when clinically appropriate
• Failure to recognize and address underlying predisposing conditions
• Inadequate supportive care and monitoring during the acute phase of illness

The successful treatment of emphysematous gastritis requires a high index of suspicion, prompt diagnosis with CT imaging, and immediate initiation of appropriate medical therapy, with surgical intervention reserved for specific indications 2, 6, 5.