Gastric Pneumatosis: A Challenge in Conservative Versus Surgical Management

Purpose: Gastric pneumatosis is an extremely rare condition with a wide spectrum of possible underlying etiology. The dilemma in managing this condition can be challenging if the underlying insult is severe. We present a patient who had abdominal pain during dialysis and was found to be having profound hypotension leading to gastric pneumatosis. An 85-year-old male patient was transferred to ER from dialysis center for abdominal pain, nausea, vomiting, and BP of 75/50. Past medical history included end stage renal disease, diabetes mellitus, and coronary artery disease. Physical examination showed abdominal distention and epigastric rebound tenderness. CT abdomen revealed gas in portal and splenic vein, gastric body wall, and fundus (Figure 2). Upper endoscopy showed severe erythema, erosion, granularity, and petechiae along the greater curvature and antrum, up to the second part of duodenum (Figure 1). After a debate for the need of urgent surgical intervention, a decision was made to manage conservatively. He received volume resuscitation, proton pump inhibitor, and bowel rest, and dialysis was resumed. He showed significant improvement and was discharged home after 6 days. It is important to have high index of suspicion for bowel wall ischemia in dialysis patients presenting with abdominal pain and hypotension. Many of these patients have chronic calcification in major abdominal arteries that increases the risk of bowel ischemia. Conservative management, as in our patient, can be enough for clinically stable patients with avoidance of unnecessary surgical intervention.Figure: Air in stomach wall displayed by arrow.Figure: Demarcation between healthy and affected gastric mucosa on endoscopy.