Archives of Academic Emergency Medicine. 2019; 7 (1); e42 PH OTO QU I Z A 92-Year-Old Man with Abdominal Pain Following In- tractable Vomiting; a Photo Quiz Chin-Chu Wu1, Aming Chor-Ming Lin2,3∗ 1. Department of Diagnostic Radiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 2. Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 3. School of Medicine, Fu-Jen Catholic University, New Taipei city, Taiwan. Received: June 2019; Accepted: July 2019; Published online: 6 August 2019 Cite this article as: A 92-Year-Old Man with Abdominal Pain Following Intractable Vomiting; a Photo Quiz. Arch Acad Emerg Med. 2019; 7(1): e42. Figure 1: Posterior-anterior chest X-ray (left) and coronal view of abdominal computed tomography scan (right) of patient. 1. Case presentation A 92-year-old man with hypertension, chronic obstructive pulmonary disease (COPD), peptic ulcer disease and demen- tia presented to the emergency department with a 2-day his- tory of abdominal pain in the left upper quadrant, distention, dry cough and intractable vomiting. On physical examina- tion, the patient had epigastric tenderness and bowel sounds were reduced. The patient’s vital signs included blood pres- sure of 168/84 mmHg, heart rate of 99 beats/minutes, res- piratory rate of 24 beats/minutes, and oxygen saturation of 95% in room air. His temperature was 37.9◦C. The rest of physical examination findings were unremarkable. Com- plete blood cell count showed the following results: leuko- cyte count 10100/mm3 with 85% segmented neutrophils, hemoglobin 12 g/dl, platelet 350000/microliter, and interna- tional normalized ratio (INR) of 0.97. Other laboratory find- ings included: glucose 167 mg/dl, blood urea nitrogen (BUN) 28 mg/dl, serum creatinine 2.0 mg/dl, sodium 135 mEq/L, potassium 3.3 mEq/L, serum glutamic oxaloacetic transam- inase (SGOT) 15 U/L, total bilirubin 0.5 mg/dl, and lipase 25 U/L. The patient underwent chest X-ray and abdominal computed tomography (CT) scan without contrast material, the results of which are shown in Figure 1. What is your diagnosis? 2. Diagnosis Chest X-ray showed left lower lung interstitial opacities and air bubble below the left hemi diaphragm (Figure 1 (left), ar- rows). Abdominal CT scan revealed intramural gas within a This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Ch. Wu and A. Lin 2 dilated stomach (Figure 1 (right), arrow). A diagnosis of gas- tric emphysema was made. 3. Case fate The patient was not toxically ill and recovered with conserva- tive management of nasogastric decompression, intravenous fluids, total parenteral nutrition and intravenous antibiotics. The patient was discharged from the hospital 7 days after presentation. 4. Discussion Gastric emphysema is characterized by the presence of air within the wall of the stomach. Gas within the stomach wall is an alarming finding on imaging. Early recognition is essential. The gas may be caused by gastric pneumatosis, also known as gastric emphysema or emphysematous gas- tritis (1). It is important to differentiate the causes of gastric pneumatosis. Gastric emphysema is usually asymptomatic and relatively benign, and resolves spontaneously with conservative treatment with bowel rest, parenteral nutrition and wide spectrum antibiotics. Gastric emphysema is a rare condition in which gas accumulates within the wall of the stomach. Gastric distension and frequent vomiting precede the formation of the intramural air. Pulmonary disease, instrumentation of the stomach, and obstructing lesions of the antrum and pylorus are also common contributing factors. Emphysematous gastritis is a lethal condition with high mor- tality (2, 3). Surgery is indicated in emphysematous gastritis because of gastric infarction, perforation or failed medical management. Emphysematous gastritis is characterized by the presence of gas in the wall of the stomach and is a severe form of phlegmonous gastritis, which develops due to invasion by gas-forming microorganisms. Air within the gastric wall along with portal venous air, sepsis and evidence of infection support the diagnosis of emphysematous gas- tritis (1, 2). The radiographic finding of gastric emphysema with hepatic portal venous gas is classically an ominous sign, associated with a high mortality rate. Diabetes melli- tus, immunosuppression, alcohol abuse, ulcerative colitis and use of non-steroidal anti-inflammatory drugs (NSAID) have all been reported as predisposing factors (4, 5). The most commonly involved microorganisms are streptococci, Escherichia coli, Pseudomonas aeruginosa, Clostridium perforins and Staphylococcus aureus. Abdominal CT scan is the diagnostic tool of choice to detect gastric pneumatosis and helps in differentiating it with gastric emphysema or emphysematous gastritis. 5. Conclusion: The presence of gas within the stomach wall may be associ- ated with a wide range of conditions, ranging from benign to fatal. Early recognition by abdominal CT scan and prompt treatment are essential to improve survival. 6. Appendix 6.1. Acknowledgements We acknowledge all the staff of diagnostic radiology and emergency departments of Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 6.2. Conflict of interest None. 6.3. Funding and support None. 6.4. Authors’ contributions All authors passed four criteria for authorship contribution based on recommendations of the Internal Committee of Medical Journal Editors. Authors ORCIDs Chin-Chu Wu: 0000-0003-2658-5775 References 1. Matsushima K, Won EJ, Tangel MR, Enomoto LM, Avella DM, Soybel DI. Emphysematous gastritis and gastric em- physema: similar radiographic findings, distinct clinical entities. World journal of surgery. 2015;39(4):1008-17. 2. Yalamanchili M, Cady W. Emphysematous gastritis in a hemodialysis patient.(Case Report). Southern medical journal. 2003;96(1):84-9. 3. Paul M, John S, Menon MC, Golewale NH, Weiss SL, Murthy UK. Successful medical management of emphy- sematous gastritis with concomitant portal venous air: a case report. Journal of medical case reports. 2010;4(1):140. 4. Jehangir A, Rettew A, Shaikh B, Bennett K, Qureshi A, Je- hangir Q. A case report of emphysematous gastritis in a di- abetic patient: favorable outcome with conservative mea- sures. Journal of community hospital internal medicine perspectives. 2015;5(4):28010. 5. Inayat F, Zafar F, Zaman MA, Hussain Q. Gastric emphy- sema secondary to severe vomiting: a comparative review of 14 cases. BMJ case reports. 2018;2018:bcr-2018-226594. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Case presentation Diagnosis Case fate Discussion Conclusion: Appendix References