S6428 Emphysematous Gastritis in a Patient With COVID Infection and Celiac Artery Stenosis

Introduction: Emphysematous gastritis (EG) is a rare and lethal entity characterized by infiltration of gas forming microbes within the gastric mucosa. Case Description/Methods: A 75-year-old man with a past medical history of dementia, hypertension, chronic kidney disease, and chronic obstructive pulmonary disease presented in the setting of unresponsiveness, and was admitted for suspected aspiration pneumonia. Vitals were notable for tachycardia and hypotension (95/66 mm Hg). Abdominal tenderness, distension and rigidity were noted on physical exam. Labs revealed an elevated white blood cells count (13.3 × 103/μL), BUN (31 mg/dL), creatinine (1.4 mg/dL) and lactate (3.3 mmol/L). Computed tomography (CT) A/P revealed a markedly distended stomach and portal venous gas without pneumoperitoneum. The esophagus was dilated with severe ostial stenosis of the celiac trunk. Empiric broad spectrum antibiotics and intravenous proton pump inhibitor were initiated. Patient was upgraded to the intensive care unit for further management. Nasogastric tube placement yielded coffee-ground aspirate. Esophagogastroduodenoscopy (EGD) and surgical intervention were deferred due to unfavorable risk benefit profile. Discussion: EG is a life-threatening condition with mortality rates as high as 61%. Patients often present with fulminant shock. Risk factors include gastroenteritis, alcohol use disorder, type 2 diabetes mellitus, end-stage renal disease, prolonged nonsteroidal anti-inflammatory drug use, malignancy, caustic ingestion and immunodeficiency. There have been cases linked to severe atherosclerosis with consequent gastrointestinal necrotic lesions which may serve as a nidus for bacterial growth. Definitive diagnosis is through abdominal CT and aspirate culture. Our case demonstrated distension of the stomach with mural gas within the cardia and antrum with presence of left hepatic venous gas. Our patient had severe flow limiting stenosis celiac trunk which serves as the primary arterial supply of the stomach. Our patient also had a concomitant coronavirus disease 2019 (COVID-19) infection. Literature on association between COVID-19 infection and EG is scarce, though there is a postulated risk of invasion of gastrointestinal angiotensin converting enzyme 2 (ACE2) receiver which can promote inflammation, disrupt barrier integrity and promote dysbiosis. Furthermore, hypercoagulability due to the vascular endothelial injury caused by COVID-19 infection may also contribute. Conservative management is with fluid resuscitation and broad-spectrum antibiotics and rarely anti-fungal coverage. Mortality is high, even with definitive surgical management. Our patient continued to deteriorate clinically despite these measures and he ultimately passed.