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Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

10.5005/jp-journals-10071-24770
Letter to the Editor
Emphysematous Gastritis: An Ominous Condition Masquerading as Enterocolitis in Immunocompromised Host
Bhosale Shilpushp J 1https://orcid.org/0000-0002-0290-0526

Joshi Malini 2https://orcid.org/0000-0001-5051-9474

Dhakne Praveen 3https://orcid.org/0000-0002-5804-1417

Kulkarni Atul P 4https://orcid.org/0000-0002-5172-7619

1 Department of Critical Care Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
2–4 Department of Anesthesiology, Critical Care & Pain, Division of Critical Care Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
Atul P Kulkarni, Department of Anesthesiology, Critical Care & Pain, Division of Critical Care Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India, Phone: +91 9869077526, e-mail: kaivalyaak@yahoo.co.in
8 2024
31 7 2024
28 8 808809
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Bhosale SJ, Joshi M, Dhakne P, Kulkarni AP. Emphysematous Gastritis: An Ominous Condition Masquerading as Enterocolitis in Immunocompromised Host. Indian J Crit Care Med 2024;28(8):808–809.

Keywords

Emphysematous gastritis
Gastric emphysema
Immunocompromised host
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pmcDear Editor,

Emphysematous gastritis is a rare, but often fatal condition, characterized by diffuse inflammation of the stomach wall with gas forming organisms, leading to gastric wall necrosis. It carries a high mortality (>60%).1 It can occur in patients with diabetes mellitus, steroids intake and other immunosuppressed conditions or postoperatively. History of NSAIDs and alcohol abuse is often present. The patient commonly presents with acute abdomen, hematemesis, melena, sepsis, and septic shock. The organisms notorious to cause this condition are Staphylococcus aureus, Streptococcus species, Escherichia Coli, Enterobacter species, Clostridium and Candida species, however, in most cases, the organism may not be identified. The condition can be diagnosed on endoscopy and/or computed tomography (CT). Imaging reveals the typical feature of thickening of gastric wall with intramural gas. Occasionally, gas may be seen in the portal venous system. Treatment involves either conservative management or surgical resection of the stomach, depending on the patient's clinical condition.

A 15-year-old male child, with relapsed high risk B cell acute lymphoblastic lymphoma presented to our ICU on day 13 of chemotherapy with abdominal pain, respiratory distress, and history of multiple loose stools. He was receiving chemotherapy in the form of high-dose methotrexate, cytarabine, L-asparaginase, and dexamethasone. He was put on mechanical ventilation due to worsening acute respiratory distress syndrome (ARDS) and received noradrenaline due to severe septic shock. With the presumptive diagnosis of severe neutropenic enterocolitis, he was treated with intravenous broad-spectrum antimicrobials (ceftazidime-avibactam, aztreonam, teicoplanin, and voriconazole). Apart from persistently elevated lactates (>8 mmol/L), other biochemistry was normal. Enzyme immunoassay for galactomannan and β-D-glucan were negative. Due to worsening condition, a CT scan was performed which showed gastric wall thickening with intramural gas in the fundal region suggestive of Emphysematous gastritis (Fig. 1). Endoscopy could not be performed due to severe hemodynamic instability. Surgeons were consulted who suggested conservative management. The blood culture was positive for S. aureus, Streptococcus pneumoniae, Pseudomonas, and Klebsiella pneumoniae. The patient's hemodynamic status worsened over the next 48 hours requiring escalating doses of vasopressors and he expired on the 3rd day after ICU admission.

Fig. 1 Computed tomography suggestive of gastric wall thickening with intramural gas

Emphysematous gastritis is of infective origin caused by either local bacterial invasion or hematogenous spread. Early diagnosis and aggressive treatment is necessary as the condition is highly fatal.2 It is also important to differentiate emphysematous gastritis from a similar condition called gastric emphysema.3 Immunosuppression remains one of the significant risk factor for development of Emphysematous gastritis.4 Gastric emphysema is non-infectious, generally benign, and self-limiting, seen in patients with mechanical causes such as gastric outlet obstruction. It presents with nausea, vomiting, often following nasogastric tube placement.5 It has good prognosis contrary to Emphysematous gastritis. Endoscopy can help to confirm the diagnosis of Emphysematous gastritis by presence of ulcers and necrosis of the gastric muscularis mucosa.

Emphysematous gastritis needs aggressive management, especially in immunocompromised patients.6 Medical management is generally preferred and includes resuscitation, appropriate antimicrobials, and organ support.7 Surgical intervention, although associated with poor outcomes, needs consideration when conservative management fails, however, the optimal timing is difficult to ascertain.8 Watson et al. stated that the incidence of surgical intervention has significantly reduced after 2000 AD, compared to before, along with statistically significant reduction in mortality (59.4 vs 33.3%, p = 0.046).1 We believe that a high index of suspicion and individualized treatment, including surgical intervention, may help in further reducing the mortality of this rare but dreaded condition.

Orcid

Shilpushp J Bhosale https://orcid.org/0000-0002-0290-0526

Malini Joshi https://orcid.org/0000-0001-5051-9474

Praveen Dhakne https://orcid.org/0000-0002-5804-1417

Atul P Kulkarni https://orcid.org/0000-0002-5172-7619

Source of support: Nil

Conflict of interest: None
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References

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2. Loi T-H See J-Y Diddapur RK Issac JR Emphysematous gastritis: A case report and a review of literature Ann Acad Med Singapore 2007 36 1 72 73 17285190 17285190
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