MON-688 Emphysematous Gastritis and Diabetes

Background: Emphysematous gastritis (EG) is a rare and severe form of gastritis of infectious origin. Diabetes is an important underlying risk factor as it leads to a systemic predisposition to infections. Other risk factors include long term steroid use, nonsteroidal anti-inflammatory (NSAID) use, alcohol use, corrosive ingestion, and pancreatitis, all of which disrupt gastric mucosa. First described in the 1800s, it is characterized by the presence of air in the stomach wall and differentials for these cases include gastric emphysema and cystic pneumatosis both of which are non-infectious in origin. Clinical Case: A 57-year-old male with type 2 diabetes presented with a one-day history of abdominal pain, non-bloody diarrhea, and vomiting. One day prior to presentation, he developed diarrhea which was followed by episodes of projectile vomiting reported as orange-tinged with mucus. On the day of admission, he was afebrile, tachycardic in 120s with stable blood pressure. Laboratory evaluation was significant for leukocytosis at 18.8 k/uL (4.3–11.3 k/uL) and lactic acidosis 2.37 mmol/L (0.7–2.1 mmol/L). Abdominal examination was notable for soft abdomen with diffuse tenderness to deep palpation without rebound or guarding. Further workup with Computed Tomography (CT) was concerning for emphysematous gastritis with air in the gastric vein, splenic vein, and portal vein. Given hemodynamic stability and benign abdominal examination, medical management was initiated. He was started on ceftriaxone and metronidazole which were continued for a total of 10 days with clinical improvement. Discussion: EG results from disruption in gastric mucosa which facilitates translocation of gas-producing bacteria commonly Klebsiella pneumonia, Escherichia coli, Pseudomonas aeruginosa, and Enterobacter subspecies. Immunosuppression with diabetes is an important underlying factor and patients are at risk even with controlled diabetes. Additionally, patients with diabetic complications like gastroparesis with frequent retching are at increased risk. Considering variable and non-specific symptoms of presentation, a high index of clinical suspicion is required for recognition as it may have a fulminant course with high mortality risk. CT scan is the imaging of choice for diagnosis. Management primarily consists of bowel rest, antibiotics and monitoring for signs of peritonitis. In the absence of complications including rupture or stricture formation, surgery is not recommended. In our case, possible gastroenteritis with subsequent vomiting and retching in the setting of underlying diabetes predisposed to the development of emphysematous gastritis. Although air in the portal venous system is associated with higher mortality, our patient was successfully managed conservatively. As the diagnosis carries a high mortality risk, early recognition is imperative for a successful outcome.