S6291 Air in the Wrong Places, But the Right Time: Conservative Management of Gastric Pneumatosis and Portal Venous Gas

Introduction: Gastric pneumatosis (GP) is a rare condition typically precipitated by forceful retching, gastric trauma, gastric outlet obstruction, gastric ulcers, and mucosal necrosis, leading to air trapping within the stomach wall. GP should be distinguished from emphysematous gastritis, which can have different precipitant causes, including hematogenous spread or direct inoculation. GP can lead to hepatic portal venous gas. Hereby, we present a case of GP and highlight its diagnosis, endoscopic findings, and management, which may help guide future cases. Case Description/Methods: A 70-year-old man with a past medical history of essential hypertension, gastroesophageal reflux disease, and diverticulosis presented to the emergency department with a 2-day history of sudden-onset epigastric abdominal pain, nausea, and vomiting. He denied similar symptoms in the past, chronic use of over-the-counter pain medications, fever, or diarrhea. Vital signs were within normal limits. Abdominal examination revealed mild epigastric tenderness but was otherwise unremarkable. Laboratory results were notable for mild hyponatremia, hypokalemia, elevated bicarbonate, and mildly elevated liver enzymes, with normal alkaline phosphatase and total bilirubin. Amylase, lipase, and lactic acid levels were within normal limits. Computed tomography (CT) abdomen and pelvis demonstrated gastric pneumatosis along the greater curvature starting from the fundus, along with hepatic portal venous gas (HPVG) extending into the left hepatic lobe. Mesenteric vessels were widely patent, with no evidence of free intraperitoneal air. Scattered diverticulosis was also noted. The patient was managed conservatively with nil per os (nothing by mouth), intravenous fluids, proton pump inhibitors, and an antiemetic. Upper endoscopy revealed a normal esophagus, a small hiatal hernia, and diffuse severe inflammation with congestion and erythema involving the gastric fundus, body, and antrum. Erythematous duodenopathy was also noted. Biopsies from the stomach revealed chronic inactive gastritis, negative for H. pylori. Surgical consultation endorsed continued conservative management. The patient experienced symptomatic improvement and was subsequently discharged. Discussion: The above patient, with clinical presentation and CT findings of GP and HPVG, likely developed these due to forceful retching from a viral illness and improved with conservative care. Surgical intervention should be reserved for patients with clinical deterioration or complications such as perforation or necrosis.