Emphysematous Gastritis
Description
• The patient is a 35-year-old male who has post-head injury hearing loss and asthma.
• Symptoms include a 2-day history of fever with chills, dry cough, nasal congestion, vomiting with blood specks, and diffuse abdominal pain (mostly middle/lower abdomen, severe, 7/10).
• Vitals: hypertensive (150/100 mmHg), febrile (101.8°F), and tachycardic (HR 125 bpm).
• Exam: Bowel sounds are preserved, and there is tenderness in the abdomen with guarding.
• Labs:
• WBC 11.7×10⁹/L (79% neutrophils), Hb 14 g/dL.
• liver enzymes that are slightly elevated (AST/ALT 88/102 U/L).
• 114 U/L of alkaline phosphatase.
• Mildly elevated lipase (56 U/L).
• Imaging: A CT scan of the abdomen and pelvis revealed modest perigastric fat stranding, intramural air collections, and circumferential thickening of the stomach wall, all of which are indicative with emphysematous gastritis.
• Patient: 81-year-old man with benign prostatic hyperplasia (indwelling Foley), anemia, dementia, hypertension, and chronic kidney disease.
• Three days of stomach pain, one day of nausea or vomiting, and coffee-ground emesis are the symptoms.
• Recent history: recent hospitalization for fecal impaction/ileus; previous endoscopy revealed mild gastritis and grade C esophagitis.
• Exam results include rebound tenderness (LLQ), normoactive bowel sounds, and a distended tympanic abdomen.
• Labs:
• WBC 16.4×10⁹/L, Hb 11.4 g/dL.
• Ammonia is 85 µmol/L, creatinine is 1.6 mg/dL, BUN is 72 mg/dL, and lactic acid is 3.0 mmol/L (↑).
• Bilirubin and liver enzymes are normal.
• EG with bowel ischemia is suggested by non-contrast CT imaging, which shows a bloated stomach with gastric wall pneumatosis, portal venous gas in the liver, a thickened ascending colon wall, and severe rectal fecal impaction.
◉ Definition & Overview
• A rare and severe infection caused by gas-forming organisms infiltrating the stomach wall is called emphysematous gastritis (EG).
• Fraenkel (1889) was the first to describe it, and Weens (1946) made the radiological diagnostic.
high death rate (~60%) as a result of sepsis, perforation, and necrosis risks.
◉ Common Causative Organisms
• Pseudomonas aeruginosa, Clostridium welchii, Enterobacter species, Streptococci, E. coli, and S. aureus.
• Proteus and Candida species are less prevalent.
• Mucor species have also been implicated in the incident.
◉ Risk Factors
• diabetes.
• drinking alcohol.
• suppression of the immune system.
• prolonged use of NSAIDs or corticosteroids.
• failure of the kidneys.
• ischemia or damage to the stomach mucosa.
• recent endoscopy or abdominal surgery.
◉ Pathophysiology
• Damage to the mucosal barrier leads to bacterial invasion of the stomach wall, which produces gas and toxins.
• may result from hematogenous spread or direct mucosal infection.
• Bacterial colonization is predisposed by ischemic damage or ulceration.
◉ Clinical Features
• Severe but nonspecific symptoms include fever, hematemesis, vomiting, nausea, abdominal pain, and sepsis symptoms (hypotension, tachycardia).
• may show up as GI bleeding or coffee-ground emesis.
• can be mistaken for other severe stomach disorders.
◉ Diagnosis
• The hallmark imaging features of a CT scan include portal venous gas, perigastric fat stranding, wall thickening, and gas inside the stomach wall.
• Endoscopy can verify a diagnosis and evaluate mucosal damage.
• Blood cultures could turn out negatively.
• It is necessary to differentiate this condition from gastric emphysema, which is a benign, non-infectious gas in the wall.
Protocol
◉ Therapy:
• Decompression of the nasogastric tubes (NG).
• IV fluids, IV pantoprazole, and broad-spectrum IV antibiotics (metronidazole, vancomycin, and piperacillin-tazobactam).
• Treatment: antiemetic (metoclopramide)
• NG decompression (coffee-ground aspirate) and intensive care unit admission.
• IV fluids and antibiotics (metronidazole, vancomycin, and piperacillin-tazobactam).
• IV bolus of pantoprazole → maintenance of BID.
• aggressive bowel practices (manual disimpaction, enemas, lactulose, senna, and docusate).
• After bacteriuria was found, the catheter was changed.
• For stable patients, early aggressive conservative therapy is preferred:
• gastric decompression (NG tube) and intravenous fluids.
• broad-spectrum antibiotics that work against anaerobic and gram-negative bacteria.
• inhibitors of the proton pump (IV).
• supportive treatment under careful observation.
• Surgery is only scheduled for:
• stomach ulcers.
• piercing.
• Peritonitis.
• Conservative management's failure.
• multidisciplinary group (infectious disease, surgery, gastroenterology, intensive care unit).
◉ Problem Faced: Emphysematous Gastritis
• A rare and potentially fatal infection of the stomach wall, emphysematous gastritis (EG) is brought on by gas-forming bacteria like Escherichia coli and Clostridium.
• Severe stomach pain, nausea, vomiting (sometimes coffee-ground emesis), sepsis, and systemic toxicity are common patient presentations.
• Portal venous gas and gastric wall pneumatosis, or gas inside the stomach wall, are common radiological findings.
• There is a significant danger of death from complications like sepsis, perforation, and stomach necrosis brought on by EG.
◉ Interventions in Medical Management
• Prompt diagnosis and treatment are essential.
• Placement of a nasogastric tube to relieve distension and decompress the stomach is known as gastric decompression.
• Broad-spectrum antibiotics that target anaerobic, gram-positive, and gram-negative bacteria are administered intravenously (IV). Vancomycin, metronidazole, cefepime, and piperacillin-tazobactam are frequently utilized.
• IV fluids: To maintain hydration and correct electrolyte imbalances.
• IV pantoprazole is a proton pump inhibitor (PPI) that lowers stomach acidity and encourages mucosal repair.
• Bowel rest: To give the gastrointestinal tract a break, patients are kept nil per os (NPO).
• Nutritional support: Parenteral nutrition, also known as IV nutrition, may be given when extended bowel rest is required.
• Complication management: Patients with severe complications, such as uncontrolled sepsis, stomach perforation, or necrosis that is not improving with medication, are eligible for surgery.
• Monitoring: Frequent laboratory and clinical assessments, such as repeat imaging (CT scans) to record resolution, liver enzymes, leukocyte counts, and blood cultures.
◉ Interventions in Nursing
• Tracking clinical status and vital signs: to quickly spot any indications of sepsis or worsening.
• The correct positioning and upkeep of the NG tube for stomach decompression is known as nasogastric tube care.
• Medication administration: IV antibiotics, PPIs, fluids, and antiemetics (such metoclopramide) should be administered promptly and correctly.
• Fluid balance: keeping an eye on intake and outflow to avoid fluid imbalance and promote proper hydration.
• Coordination of nutritional support: Working with the medical staff and dietitians to provide parenteral nutrition when bowel rest is necessary.
• Comfort and symptom management: Using medicine and positions to control nausea, vomiting, and stomach discomfort.
• Strict aseptic procedures are used in infection control to avoid secondary infections, particularly while caring for catheters.
• In order to lower fear and increase compliance, patient education and psychological support involve outlining the ailment, prognosis, and treatment strategy.
• Preparation for a potential surgical intervention: Informing the patient and their family that surgery may be necessary in the event that medical therapy is ineffective.
Notes
FOR MORE DETAILS VISIT: https://pmc.ncbi.nlm.nih.gov/articles/PMC10783959/?utm_source=chatgpt.com
