What is the management approach for emphysematous gastritis diagnosed on CT scan?

Management of Emphysematous Gastritis Diagnosed on CT Scan

The initial management of emphysematous gastritis should be conservative with nothing by mouth, intravenous fluid resuscitation, proton pump inhibitors, and broad-spectrum antibiotics covering gram-negative organisms and anaerobes, with surgical exploration reserved only for cases that fail non-operative management, demonstrate clinical deterioration, or develop signs of peritonitis. 1

Diagnostic Confirmation

• CT scan is the imaging modality of choice for diagnosing emphysematous gastritis, characterized by:

  • Presence of gas within the gastric wall
  • Gastric wall thickening
  • Possible portal venous gas
  • Possible free intraperitoneal air 1, 2

• Laboratory studies should include:

  • Complete blood count (CBC)
  • Comprehensive metabolic panel (CMP)
  • Liver enzymes
  • Renal function tests
  • Blood cultures to identify causative organisms 3

Conservative Management Protocol

1. Immediate Interventions:

   • Nothing by mouth (NPO)
   • Intravenous fluid resuscitation
   • Proton pump inhibitors (PPI) therapy
   • Broad-spectrum antibiotics covering gram-negative organisms and anaerobes 1, 4

2. Monitoring:

   • Close clinical monitoring for signs of deterioration
   • Serial laboratory tests to track inflammatory markers
   • Repeat CT scan in 3-4 days to assess resolution of pneumatosis 1

3. Nutritional Support:

   • Consider enteral feeding via nasogastric tube or jejunostomy if oral intake will be restricted for extended periods 3

Indications for Surgical Intervention

Surgery should be considered only in the following scenarios:

• Failure of conservative management
• Clinical deterioration despite appropriate medical therapy
• Development of peritonitis
• Gastric perforation with signs of septic shock 1, 5

Special Considerations

• Even in the presence of portal venous air or pneumoperitoneum, emphysematous gastritis should not be considered an absolute indication for surgical exploration 1
• Contained gastric perforation as a complication of emphysematous gastritis can potentially be managed non-operatively in selected cases 5
• Predisposing factors that should be addressed include:
  • Diabetes control
  • Corrosive ingestion
  • Alcohol abuse
  • Immunosuppression 4

Follow-up

• Repeat CT scan in 3-4 days to confirm resolution of pneumatosis
• Gradual reintroduction of oral diet once clinical improvement is observed and repeat imaging shows resolution
• Address underlying predisposing factors to prevent recurrence 1, 6

Prognosis

Emphysematous gastritis has historically been associated with high mortality rates, but early recognition and prompt initiation of appropriate therapy can significantly improve outcomes. Conservative management has shown success in recent case reports, even in patients with extensive portal venous gas or free intraperitoneal air 1, 6.