Abstract
The presence of air in the gastric wall is being diagnosed more often nowadays especially in the era of CT scan. In addition to life-threatening conditions as ischemia, benign causes are probably more common. We present two case reports in which air pockets were seen in the gastric wall after repeated attacks of retching. Patient 1: 60-year-old male presented with 2 days history of retching and abdominal pain. He denied significant vomiting or fevers. Medical history was significant for dysphagia that was treated with endoscopic esophageal dilation, atrial fibrillation and diabetes mellitus. Physical exam showed dehydration with epigastric tenderness. Lab work was significant for leucocytosis (16000/pl) and lactic acid of 2.8mmol/l. CT scan showed gastric distension and emphysemia with air in the portal vein system. He was admitted to the intenstive care unit and was treated with iv antibiotics and iv fluids. Insertion of a nasogastric tube lead to dramatic resolution of symptoms. Upper endoscopy revealed esophageal stricture and mucosal disruption of gastric mucosa. Patient was discharged after two days. Patient 2: 41-year-old female presented with a severe episode of headache, bilious vomiting, bouts of retching. She has a medical history of migraine, atrial fibrillation and diabetes mellitus. Her headaches have not been well controlled. She was tachycardic with diffuse abdominal tenderness. Her white cell count was 14800/pl and potassium was 3meq/l. CT scan showed submucosal gas throughout the body and fundus of the stomach. The patient was treated with iv fluids. Nasogastric tube was placed. Upper endoscopy showed diffuse gastric erythema and submucosal hemorrhages. The rest of her hospital course was unremarkable and she was discharged after tolerating regular diet. The phenomenon of air infiltration of the stomach wall may occur due to increased intragastric pressure and severe distension, especially when the patient develops aerophagia during retching maneuvers, while being unable to expel air (e.g. by belching). The presence of a valve-like mechanism as in esophageal stricture or gastric outlet obstruction may increase the stomach volume and accentuates the air leak into the portal vein system. Though more serious etiologies should be excluded, we recommend that gastric decompression and iv fluids should remain as the mainstay of therapy, since most of the cases will resolve spontaneously with no need for surgical interventions.