Formosan Journal of Surgery

: 2018  |  Volume : 51  |  Issue : 3  |  Page : 129--131

Emphysematous gastritis after radical subtotal gastrectomy for advanced gastric cancer

Jou-Chien Liao1, Chung-Wei Lin2,  
1 School of Medicine, National Yang-Ming University, Taipei, Taiwan
2 School of Medicine, National Yang-Ming University; Department of Surgery and Surgical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan

Correspondence Address:
Dr. Chung-Wei Lin
No. 125 Lih-Der Road, Pei-Tou District, Taipei 112


Emphysematous gastritis is a rare but severe disease characterized by air within the gastric wall. It is commonly caused by a bacterial infection and carries a remarkably high mortality rate (50%–60%). The most common predisposing factors include ingestion of corrosive substances, alcohol abuse, and recent abdominal surgery. Diagnosis of emphysematous gastritis is difficult and relies on computed tomography (CT) scan because of the nonspecific clinical presentation of abdominal pain with systemic toxicity. In this report, we present a case of a 78-year-old male with gastric adenocarcinoma who underwent laparoscopic radical subtotal gastrectomy. After the operation, he complained of severe abdominal pain and fever. Subsequently, the patient developed acute respiratory distress syndrome and septic shock. A CT scan performed on postoperative day 17 revealed extensive intramural gas in the stomach. The patient was diagnosed with emphysematous gastritis and received conservative treatment.

How to cite this article:
Liao JC, Lin CW. Emphysematous gastritis after radical subtotal gastrectomy for advanced gastric cancer.Formos J Surg 2018;51:129-131

How to cite this URL:
Liao JC, Lin CW. Emphysematous gastritis after radical subtotal gastrectomy for advanced gastric cancer. Formos J Surg [serial online] 2018 [cited 2021 Sep 23 ];51:129-131
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Full Text


Emphysematous gastritis, first described by Fraenkel in 1889,[1] is a rare but severe variant of gastritis characterized by air in the gastric wall due to an invasion of gas-forming organisms. Despite extremely low incidence, with approximately 90 cases reported worldwide, it has fulminating clinical presentation including abdominal pain, sepsis, shock, and a very high mortality rate (50%–60%).[2] Diagnosis of emphysematous gastritis is often delayed because the symptoms are not specific. Here, we present a case of emphysematous gastritis after subtotal gastrectomy for advanced gastric cancer that was diagnosed incidentally by computed tomography (CT) scan.

 Case Report

A 78-year-old male with underlying disease of diabetes, chronic obstructive pulmonary disease (COPD), and asthma was diagnosed with advanced gastric adenocarcinoma. He underwent laparoscopic radical subtotal gastrectomy and Roux-en-Y anastomosis smoothly. After the operation, he complained of unusual abdominal pain, but there were no other abnormal findings until postoperative day 3. Fever, neutrophilic leukocytosis, and tenderness over his upper abdomen were noted. Emergent laparoscopic exploration was performed, but there was no evidence of anastomotic leakage. An antibiotic (cefmetazole 200 mg in vitro fertilization [IVF] Q12H) was given, but the patient developed acute respiratory distress syndrome (ARDS) and septic shock. On the 8th day after the first operation, bilious fluid was noted from a Jackson-Pratt (J-P) drain, and a CT scan showed duodenal stump leakage. Fortunately, it was localized and well drained, so conservative treatment was given, and antibiotic treatment was changed to piperacillin/tazobactam (4500 mg, IVF Q8H).

A CT scan performed on the 17th postoperative day showed no abscess in the abdomen, but air in the gastric wall was noted [Figure 1]. A chest radiograph also showed collections of gas contouring to the stomach wall [Figure 2]. The diagnosis of emphysematous gastritis was established. Bleeding had been noted from the nasogastric tube since postoperative day 20, and it was treated with proton pump inhibitor agents (pantoprazole 40 mg Q8H) and blood transfusion. An esophagogastroduodenoscopy showed mild edematous and hemorrhagic spots over the gastric mucosa consistent with gastritis [Figure 3]. A culture performed on the drainage from the J-P drain and the nasogastric tube both yielded Klebsiella pneumoniae.{Figure 1}{Figure 2}{Figure 3}

At the time of diagnosis, the patient suffered from severe ARDS, and he was not fit for surgery. The patient continued receiving conservative treatment with parenteral nutrition and antibiotics, including ciprofloxacin (400 mg, IVF, Q12H), metronidazole (500 mg, IVF Q8H), and vancomycin (1000 mg, IVF Q12H). He recovered gradually, and air within the stomach wall in chest radiographs disappeared within a week. A tracheostomy was performed but weaning off of the ventilator failed because of his underlying COPD and post-ARDS pulmonary fibrosis. He was transferred to a subacute respiratory care unit on postoperative day 41 for further management.


Emphysematous gastritis was first described by Fraenkel in 1889, and the radiological diagnosis was first made by Weens in 1946.[3] Emphysematous gastritis is defined as the invasion of the gastric wall by a gas-producing infection that results in intramural air formation and systemic toxicity.[1] Only 69 cases have been reported in English literature from 1889 to 2014.[4] The mortality rate of emphysematous gastritis has been reported to be as high as 61%.[2] However, as the techniques and management strategies have improved, the mortality rate dropped to 33% in patients who developed emphysematous gastritis after 2000.[4]

The stomach is the least common site affected by gas-forming organism because of its excellent blood supply, acidic pH, and mucosal barrier.[5] However, several risk factors such as ingestion of corrosive substances, alcohol abuse, abdominal surgery, diabetes, gastric infraction, underlying malignancy, immunosuppression, and nonsteroidal anti-inflammatory drug usage [2],[4] may disrupt the integrity of the gastric mucosa and increase the susceptibility to emphysematous gastritis.[6]

The most common reported infective organisms of emphysematous gastritis are Streptococci species, Escherichia coli, Enterobacter species, Clostridium welchii, and Staphylococcus aureus. Fungal infections, usually the Candida species or Mucormycosis, have also been reported.[2],[6] In our patient, the infective organism was Klebsiella pneumonia, which was determined from cultures performed on the nasogastric aspirate and a J-P drain.

Clinical presentation of emphysematous gastritis is usually fulminant. The symptoms include abdominal pain, nausea, vomiting, diarrhea, melena, hematemesis, signs of hemodynamic instability, and leukocytosis.[6] Immunocompromised patients, on the other hand, sometimes exhibit more subtle clinical presentations.[7] Since most of the symptoms of emphysematous gastritis are not specific, the diagnosis is difficult and relies primarily on radiography. A CT scan is currently the most effective diagnostic imaging modality as it is both highly sensitive and specific in the detection of intramural air. Characteristic findings in a chest radiograph or a plain abdominal radiograph are gas bubbles contouring to the wall of the stomach regardless of how the patient is positioned.[8]

The main differential diagnoses for gas within the stomach wall include emphysematous gastritis and gastric emphysema. Gastric emphysema is a benign, asymptomatic, and self-limited condition caused by gas entering the stomach wall through a mucosal defect not related to infection.[9] Therefore, clinical presentations help to distinguish between the two conditions. The diagnosis of our patient was based on both clinical presentations of severe abdominal pain, fever, and septic shock along with the radiological features of extensive gas within the stomach wall, which did not appear until the 17th postoperative day.

Early diagnosis and intervention are the most important factors in improving the prognosis. Traditionally, most patients would undergo an urgent laparotomy. However, recent studies suggested that surgery failed to significantly improve survival and was associated with a high risk of postoperative complications, such as anastomotic leakage and gastric stricture.[10] Consequently, conservative treatment with broad-spectrum antibiotics, bowel rest, and parenteral nutrition was recommended to be considered before surgery in patients without perforation or peritonitis.[4],[10] In our case, the positive effects of conservative treatment appeared soon after the treatment began.


Emphysematous gastritis is a rare but severe disease characterized by intramural gas in the stomach. It is commonly caused by gas-forming bacterial infection and carries a very high mortality rate. Diagnosis is challenging and primarily depends on a CT scan because of the nonspecific clinical presentation, especially in immunocompromised patients. Early recognition and adequate treatment are essential to improve survival.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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