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• W2004642715 abstract "Gastric pneumatosis, air in the stomach wall, is uncommon but when present is usually an ominous sign of stomach wall invasion by gas-forming organisms. Here, we report a patient who developed gastric pneumatosis from intractable vomiting after chemoradiation for cholangiocarcinoma and recovered with conservative management. A 79-year-old woman with a medical history of cholangiocarcinoma, thromboembolic disease, and gastroesophageal reflux presented with nausea, vomiting, and diarrhea of one week's duration, associated with colicky abdominal pain. She had intrahepatic cholangiocarcinoma extending into the porta hepatis, which had been found a few months before this admission. Her cancer was locally advanced and unresectable. At the time of diagnosis, she required external biliary drainage to relieve biliary obstruction by the tumor growth. Before the index admission, she had received three cycles of gemcitabine/cisplatin, then switched to chemoradiation therapy with capecitabine approximately three weeks before her presentation. Her vital signs on admission were unremarkable, and she was afebrile. The abdomen was soft and nontender, with normal bowel sounds. Her blood counts did not show leukocytosis. Enteral infection with Clostridium difficile was ruled out by stool polymerase chain reaction testing at admission. Supportive management with intravenous fluid replacement and, serially, ondansetron, metoclopramide, olanzapine, haloperidol, fosaprepitant, octreotide, and loperamide, and pain control with opioids did not control her symptoms. She required aggressive treatment with potassium and magnesium, which was attributable to her persistent diarrhea and renal wasting from cisplatin. Her hospital course was complicated by altered mental status assumed to be the result of opioids. Abdominal distention with tympany on percussion started a few days after admission; her abdomen became tender on deep palpation. Abdominal radiographs showed gastric dilation with air in the wall of the stomach vs. extraluminal gas, with small bowel dilation (Fig. 1a). Computed tomography (CT) scan of the abdomen showed lower esophageal and gastric intramural gas with distal small bowel obstruction (Fig. 1b). The serum lactate level at that time was 3.6 mmol/L and decreased to 2.1 mmol/L the next day with more aggressive fluid replacement. She had a nasogastric tube inserted for decompression and was started on empiric broad spectrum antibiotics for possible infection of the gastric wall with gas-forming bacteria although she remained afebrile and hemodynamically stable. A few days later, her abdominal pain improved, nausea resolved, and she tolerated a diet. Antibiotics were stopped because of the low probability of infection; blood cultures remained negative for microbial growth. Repeat abdominal radiographs demonstrated objective resolution of the gastric pneumatosis. Upper endoscopy only showed mild gastric erythema, and biopsies showed chronic inactive gastritis with no evidence of Helicobacter pylori infection. Her final diagnosis was acute radiation enteritis complicated by gastric pneumatosis and small bowel obstruction. Restaging CT scan of the abdomen 11 weeks later confirmed resolution of the gastric intramural gas. To our knowledge, this is the first reported case of chemoradiation-induced gastric pneumatosis that resolved with conservative measures. Gastric pneumatosis is a rare diagnosis with a wide range of clinical presentations. It can be caused by the deadly (emphysematous gastritis), a gangrenous stomach, to the benign (gastric emphysema). Gastric ischemia is a rare cause, given the rich vascular supply of the stomach but pneumatosis from ischemia can occur if gastric pressure increases dramatically.1Kim S.J. Cho H. Lee S.W. Choi S.H. Hong Y.S. Gastric pneumatosis and acute massive gastric dilatation without specific cause.J Emerg Med. 2013; 44: e111-e113Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Gastric pneumatosis is reported with gastric obstruction by a tumor or pyloric stenosis. It has been rarely reported with obstructing intra-abdominal cancers such as in cholangiocarcinoma, duodenal adenocarcinoma, and pancreatic adenocarcinoma, and when patients survive, it is usually because of surgical intervention to relieve gastric outlet obstruction;2Holt R.W. Dekker J. Gastric pneumatosis intestinalis associated with cholangiocarcinoma.South Med J. 1986; 79: 79-80Crossref PubMed Scopus (13) Google Scholar, 3Bilici A. Karadag B. Doventas A. Seker M. Gastric pneumatosis intestinalis associated with malignancy: an unusual case report.World J Gastroenterol. 2009; 15: 758-760Crossref PubMed Scopus (8) Google Scholar commonly, patients die soon after the diagnosis.4Ramos J.A. Festic E. Images in clinical medicine. Catastrophic gastroduodenal pneumatosis.N Engl J Med. 2014; 371: e19Crossref PubMed Scopus (3) Google Scholar The mechanism of gastric pneumatosis in our patient is presumed to be the result of air entry into the stomach wall through a small mucosal tear from recurrent vomiting and increased gastric wall friability in the setting of chemoradiation-induced mucosal damage. CT scan is the gold standard for detecting gastric pneumatosis. The presence of extra gastric gas (in other bowel loops, portal veins, or free air in the abdominal cavity) suggests emphysematous gastritis.5Johnson P.T. Horton K.M. Edil B.H. Fishman E.K. Scott W.W. Gastric pneumatosis: the role of CT in diagnosis and patient management.Emerg Radiol. 2011; 18: 65-73Crossref PubMed Scopus (23) Google Scholar Conservative management as in our patient, with gastric decompression and supportive measures, is important, as is ruling out gastric gangrene from infection. Clinical presentation and context are important in separating the two. In conclusion, gastric pneumatosis is a rare complication of gastrointestinal cancers and chemoradiation therapy. Clinical presentation, context, and CT findings help distinguish between the self-limiting gastric emphysema and the life-threatening gastric gangrene." @default.
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• W2004642715 title "Gastric Pneumatosis: An Unexpected Complication of Intractable Vomiting in Gastrointestinal Cancers" @default.
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