Air in the stomach wall: A case Stomach diseases presentation and summary of the literature

MARTIN S. LANDIS, B.S., D. 0. Detroit, Michigan

Air in the stomach wall is rare, but its ing electrolyte studies were within normal presence can be demonstrated limits. The child, who had been born pre- maturely, had been observed frequently since radiographically. Early recognition of birth and had exhibited signs of mongolism the of air in the stomach (Downs syndrome), inability to take solid wall is essential because of the high foods, and frequent attacks of pneumonia mortality associated with five of the attributed to aspiration of gastric contents six conditions in which this sign from .

appears. The literature is reviewed for Radiographic findings cases in which this sign is present. Chest films were taken on June 1, 1964, at the A case is reported which demonstrates termination of the patients last previous stay the classic features of in the hospital (Fig. 1). They reveal evidence cystoides intestinalis on the basis of the of a persistent chronic bronchitis and inter- proposed criteria for classification of stitial pneumonitis. Chest and abdominal air in the stomach wall. Knowledge films were taken on June 9, 1964, the day of the patients admittance to the hospital (Fig. of the mechanisms producing its 2). The chest again reveals evidence of radiologic signs is essential if the chronic bronchitis and pneumonitis. The ab- correct treatment is to be dominal film shows a marked distention of the initiated promptly. stomach with what appears to be a mass filling the stomach cavity outlined by an air density. This gives the appearance of a large bezoar. An abdominal film was taken 6 hours later on the same day (Fig. 3, left). Again Air in the stomach wall is a rare finding. Its there is evidence of what appears to be a large recognition radiographically can be lifesaving. mass outlined by air within the stomach. On The following is the report of a case observed June 10, 1964, an abdominal film (Fig. 3, at Grandview Hospital, Dayton, Ohio, in June right), was taken after aspiration of 200 ml. 1964. of fluid from the stomach. At this time it was again noted that there still appeared to be a Case report mass in the stomach outlined by air. It was Case history also felt that the stomach appeared to show A 21/2-year-old boy was admitted to Grand- considerable thickening of its walls, suggest- view Hospital on June 9, 1964, with the chief ing the possibility of a phlegmonous . complaint of frequent emesis during the past An upper gastrointestinal examination was 48 hours. His admitting temperature, which done on June 10, 1964 (Fig. 4). The barium was 102 F. rectally, spiked to 104 F. and re- within the stomach revealed an air density turned to normal the following day. On June paralleling the outline of the stomach. This 10, 1964, the stomach was aspirated and 200 air density was felt to lie between the mucosa ml. of a dark brown fluid were removed. Find- and the submucosal layers of the stomach ings of routine laboratory procedures includ- wall. It resulted in a complete outlining of the

738/90 stomach wall with air. No intraluminal filling defects were noted, nor were there any areas of displacement of the stomach to suggest extragastric mass lesions. The ap- peared to be somewhat redundant and large. The 2-hour delay film revealed a persistent dilatation of the duodenum with a consider- able amount of barium being retained in the stomach. However, there was some evidence of barium in the , but no un- usual appearance of air density was seen about the remaining portion of the gastro- intestinal tract. After this examination em- Fig. 1. Top, anteroposterior view of the chest; bottom, physematous gastritis was given as a tenta- right lateral view of the chest June 1, 1964, showing evidence of persistent chronic bronchitis and inter- tive diagnosis. stitial pneumonia bilaterally. On June 11, 1964, abdominal films (Fig. 5) were again taken and showed a considerable amount of the barium contrast retained with- previous day, although there is some persist- in the large dilated duodenal cap. Otherwise ence of thickening of the gastric wall and the barium was seen to pass through the large evidence of subserosal gas in the various seg- bowel with little or no change in the small- ments of the gastric wall. intestinal pattern. The amount of gas con- On June 12, 1964, an upper gastrointestinal tained within the stomach wall is believed examination (Fig. 6) was again performed, to be considerably less than that seen on the with the barium contrast being administered

Fig. 2. Left, posteroanterior view of the chest; center, right lateral view of the chest; and right, supine abdo- men, June 9, 1964, showing persistent chronic bronchitis and pneumonitis, and marked distention of the stomach with what appears to be a mass filling the stomach cavity outlined by an air density.

Journal AOA/vol. 66, March 1967 739/91 Fig. 3. Left, supine taken 6 hours later on June 9, 1964; right, supine abdomen taken after aspiration of 200 ml. of fluid from the stomach on June 10, 1964; again there still appears to be a mass in the stomach out- lined by air. Thickening of the gastric wall. suggested phlegmonous gastritis.

Fig. 4. Left, upper gastrointestinal examination done on June 10, 1964; right, 2-hour delay film on June 10, 1964. The barium within the stomach reveals an air density paralleling the outline of the stomach. This air density is believed to lie between the mucosa and the submucosal layers and completely outlines the stomach wall. There is a persistent dilatation of the duodenum noted on the 2-hour delay film with considerable gastric retention of the barium.

through a nasogastric catheter. Once more a wall of the duodenum. The markedly dilated persistent thickening of the gastric wall was bulb with a narrow post-apical segment was noted with a small amount of subserosal gas suggestive of a congenital stenosis or a remaining within the stomach wall. The distal duodenal diaphragm of the second portion of one third of the appeared dilated, the duodenum. and the mucosa of the esophagus suggested On June 13, 1964, a further abdominal film changes in keeping with that of . (Fig. 7) revealed evidence of barium contrast No definite air density was noted within the distributed throughout the entire colon. There

740/92 Fig. 5. Left, supine abdomen; right, right lateral abdomen. These films were taken on June 11, 1964, and again show considerable amount of barium contrast retained in the duodenal bulb. The amount of gas contained within the stomach wall is believed to be considerably less than that seen on the previous day. The gas now appears to lie subserosally.

Fig. 6. Left, repeat upper gastrointestinal examination posteroanterior film; center, right anterior oblique film; right, right lateral film. Examination was done on June 12, 1964, with barium contrast administered by naso- gastric catheter. Again there was a persistent thickening of the gastric wall and a small amount of subserosal gas within the stomach wall. The distal one third of the esophagus appears dilated and the mucosa suggests changes in keeping with those of esophagitis. There is again seen the markedly dilated bulb of the duodenum with a narrow post-apical segment suggestive of a congenital stenosis or duodenal diaphragm. was again evidence of gastrectasis, showing period of 96 hours air was observed within no significant change from the previous exami- the gastric walls, first being submucosal, di- nation. The thickening and gas noted within minishing in amount each day, and finally the stomach wall were still present. For a residing subserosally.

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large quantities of blood. The course is rapid, followed by prostration with shock appearing early. The temperature elevation is high with a range of 104 to 105 F. along with a rapid pulse and an increased leukocyte count. The differential diagnosis between phlegmonous gastritis and emphysematous gastritis is made solely on the roentgen findings of air within the stomach wall. In both conditions the stomach wall is thickened and shows marked edema. Gastric emphysema is differentiated from emphysematous gastritis on roentgen findings by the fact that in gastric emphysema the air appears as a thin, translucent band as though it were seen in the tissue plan, while in emphysematous gastritis the air is collected in multiple blebs of various shapes forming irregular radiolucent bands outlining the stomach. Another finding in gastric emphy- sema is that there has almost always been Fig. 7. Supine abdomen taken on June 13, 1964, show- ing the barium contrast distributed throughout the an instrumentation or gastroscopic examina- entire colon. There is evidence of gastrectasis. The tion preceding the appearance of the air with- thickening and gas noted within the stomach wall is in the stomach wall. It may also be noted that still. persistent although much reduced from earlier examinations. in gastric emphysema the air has a tendency to disappear within 72 hours. In pneumatosis cystoides intestinalis, air in Differential diagnosis the submucosal or subserosal area of the The differential diagnosis of radiologic find- intestine may appear either in small -like ings presented a possibility of a foreign clusters or large polypoid groups or linear body or bezoar, phlegmonous gastritis, em- shadows of air density radiolucency. These physematous gastritis, gastric emphysema, shadows have been known to occur through- or pneumatosis cystoides intestinalis. The out the entire intestinal tract, having been first supposition of foreign body or bezoar was most commonly observed at operation or at eliminated by the administration of barium autopsy. The diagnosis of pneumatosis cys- contrast. However, a new problem presented, toides intestinalis of the gastric wall is made that of air within the stomach wall. Henry,1 by a process of elimination of the previously in the description of the cases of emphysema- mentioned conditions. In adults the air in the tous gastritis remarks that the symptoma- stomach wall is noted to lie subserosally, tology of phlegmonous gastritis and emphy- in children, submucosally.2 sematous gastritis is similar. There is marked Necrotizing is a destructive epigastric pain with and vomiting of inflammatory disease of the gastrointestinal

742/94 wall found in premature newborn infants.3 pancreas situated extraluminally and encir- Apparently, the first mention of this entity cling the duodenum around three fourths of in the United States was in 1964. Previous the circumference. This lesion lay just distal reports have appeared in Europe. In this to the duodenal diaphragm. It was felt by the condition, due to the weakness and deteriora- surgeon that the aberrant pancreas was not tion of the intestinal wall, air escapes into the sufficient to cause an impediment of normal wall of the intestines and may spread either flow. It is apparent on review of the findings cephalad or caudad, depending on the amount that the duodenal diaphragm causing partial of pressure and air swallowed by the infant obstruction and retention of gastric contents after birth. would cause a gastritis with edema of the Gangrene of the stomach and intestines gastric wall associated with recurrent nausea occurs when the arterial supply to these and vomiting. Esophagitis could also be pres- organs is inhibited or occluded. Collateral or ent, and the findings of pneumonitis could be by-pass circulation from the artery of Drum- attributed to the aspiration of the gastric mond is also inhibited. The tissues affected contents. The retardation of the child was undergo necrosis with gas being formed intra- felt to be secondary in the series of events murally as a by-product of the necrotizing that led to the diagnosis of pneumatosis cys- process. Air can also be lodged intramurally toides intestinalis of the gastric wall due to because of the normal presence of air intra- congenital duodenal diaphragm with aspira- luminally within the . tion pneumonia. At the time of surgery the The air is forced via the weakened mucosal surgeon did not demonstrate any air or evi- lining by coughing, vomiting, or obstructive dence of a rent in the gastric or duodenal peristalsis. mucosa to account for passage of the air intramurally. No air was demonstrable intra- Surgical findings murally. The patient was sent to Childrens Hospital in Cincinnati, Ohio, with the radiographic diag- Discussion nosis of pneumatosis cystoides intestinalis The anatomic considerations of the histology subsequent to incomplete duodenal obstruc- of the stomach wall reveal six layers. The tion, and aspiration pneumonia. After abdomi- inner layer is called the mucosa, which is nal exploration, the surgeon reported the separated by the lamina propria from the presence of a duodenal diaphragm with incom- muscularis mucosa. The muscularis mucosa plete occlusion of the duodenum. There was a is then separated by the submucosa from the small pinhole perforation in the center of the muscle layer. Surrounding the muscle layer duodenal diaphragm. This permitted some on the outside of the stomach wall is the flow of fluid and the barium contrast through serosa. the duodenum into the small intestine. It also Air or gas within the gastrointestinal wall accounted for the large distention of the is innocuous in itself. It is usually transported duodenal bulb. It might be noted that in the by the lymphatics, as demonstrated by Tung literature congenital duodenal diaphragm has and Ngai7 and supported by Jackson, 8 and been reported only about ninety times.3,6 disappears in 24 hours to 3 weeks. An associated finding was an aberrant In children the precursors for setting the

Journal AOA/vol. 66, March 1967 743/95 TABLE 1. CASES REPORTED IN THE LITERATURE OF AIR IN THE STOMACH WALL Author Year Age Sex Diagnosis Mortality Radiographic Comments evidence 1. Fraenkelis 1889 35 years M Emphysematous Died None Rod-like organisms found at autopsy gastritis 2. Maassli 1904 7 months M Pneumatosis Died None Autopsy showed cystoides chylous intestinalis 3. Mullerl6 1912 11 weeks M Pneumatosis Died None Autopsy showed cystoides evidence of hypertrophic intestinalis 4. Morton Autopsy showed 1928 75 years M Emphysematous Died None and Stabins19 gastritis evidence of Clostridium welchii 5. Weens29 1946 37 years M Emphysematous Died Yes Autopsy showed gastritis 6 months evidence of Proteus; after x-rays Aerobacter aerogenes was present 6. Chamberlin 22 1947 42 years M Gastric Lived Yes Lesser-curvature ulcer emphysema found at surgery 7. Welch 1947 15 years F Emphysematous Lived Yes Cultures of vomitus and Jones gastritis revealed Escherichia coli, nonhemolytic strep- tococci, and Staphylococcus aureus 8. Myhre 1948 53 years M Gastric Lived Yes Evidence of duodenal and Wilson2:, emphysema ulcer; on instrumenta- tion patient had acute abdominal pains 9. Myhre 1948 19 years M Gastric Lived Yes Prior to instrumentation and Wilson25 emphysema patient had vomiting and for 24 hours 10. Fierst 1951 51 years M Gastric Lived Yes After instrumentation et al.23 emphysema and surgery two gastric ulcers were noted 11. Henry 1952 1 month M Emphysematous Died Ycs Autopsy showed evi- gastritis dence of Escherichia coli; clinical findings noted mongolism 12. Cancelmo2 1954 71 years F Gastric Lived Yes Patient had carcinoma emphysema of the esophagus and associated broncho- pneumonia 13. Farfel 1956 76 years M Emphysematous Lived None Culture of vomitus and Eichhorni7 gastritis revealed Proteus and Aerobacter aerogenes 14. Lumsden24 1956 83 years M Gastric Lived Yes No instrumentation or emphysema intubation of patient 15. Plachta 1957 67 years M Non-bacterial Died None Rupture of pulmonary and Speerit gastric bullous emphysema into emphysema esophageal wall and hence to stomach wall 16. Druckmann 1961 54 years M Pneumatosis Yes Lived There were associated et al26 cystoides duodenal ulcer, vomit- intestinalis ing, and a thick gastric mucosa 17. Plachta 1961 55 years M Non-bacterial Died None Rupture of pulmonary and Speern gastric bullous emphysema emphysema Died 18. Plachta 1961 78 years F Non-bacterial None Rupture of pulmonary and Speeri2 gastric bullous emphysema emphysema 1961 46 years M Non-bacterial 19. Plachta Died None Rupture of pulmonary and Speer2 gastric bullous emphysema; emphysema history of multiple sclerosis Keyting 1961 Pneumatosis Lived 20. Yes Patient was under et al.9 cystoides treatment for tuber- intestinalis culosis of the lung

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21. Gonzales 1963 61 years M Emphysematous Lived Yes Asthmatic. Air noted 14 et al29 gastritis days after gastric surgery with intubation. Necrotic cast of stom- ach. Air present 15 days. Cultures showed Pseudomonas aerugi- nosa, Escherichia coli, Aerobacter aerogenes, and non-hemolytic Streptococcus 22. Gonzales 1963 44 years M Emphysematous Lived Yes One month after gastric et al29 gastritis surgery with intubation. Necrotic cast of stomach. Air present 22 days 21. Elliott 1963 37 years F Pneumatosis Lived Yes There was evidence of a and Elliott27 cystoides gastric ulcer associated intestinalis with vomiting 22. Dasse128 1964 63 years F Gangrene of Died Yes Massive infarction of the stomach the gastrointestinal tract after surgery of the colon. Celiac axis thrombosis 23. Berdon 1964 36 hours F Necrotizing Died None Autopsy showed air et al.3 enterocolitis within stomach wall 24. Berdon / weeks F Necrotizing Died Yes Findings were confirmed 1964 2 1 2 et al.3 enterocolitis at autopsy ; also gas in portal veins F Emphysematous Lived Yes Onset 13 days after 25. Han, Collins, 1965 44 years and Petrany30 gastritis ingestion of 23 per cent hydrochloric acid and nasogastric intubation. No culture obtained 28. Landis 1967 2 1/2 years M Pneumatosis Lived Yes Surgical findings of cystoides duodenal diaphragm intestinalis with pinhole opening associated with vomiting and aspiration pneumonia

conditions necessary to permit intramural air are present in the gas within the stomach wall of the gastrointestinal tract may be an ob- they must have arisen from the gastrointesti- structing lesion of the gastrointestinal tract, nal tract below the duodenal bulb, which is an inflammation—usually of long standing, their natural habitat. If bacteria are not an associated pulmonary disease, a poor gen- demonstrable then the air or gas must have eral condition, bacterial infection, and possibly reached the intramural site as postulated by prematurity and evidence of mental retarda- Keyting and co-workers," Doub and Shea," ,.. tion. and Plachta and Speer. 11,12 The formation of In adults the precursors to air within the or linear shadows intramurally is de- stomach wall may be an obstruction of the pendent solely on the gas pressure main- gastrointestinal tract, debilitation associated tained. It follows the line of least resistance ; with pulmonary diseases such as allergy, hence, shape, location, and extension are asthma, or pulmonary emphysema, bacterial dependent upon the source of gas or air. There infection, the history of instrumentation or may be a continuous pumping of the air from intubation, or a previous major abdominal the lung or gas produced by gas-forming bac- operation. teria or a persistent rent within the gastro- If gas in the stomach wall lies distal to the intestinal wall with air insufflation maintain- site of obstruction it is propelled there by ing the pressure. peristalsis. If the gas in the stomach wall lies In reviewing the reported cases of air with- proximal to the site of obstruction it may in the stomach wall, I found two conditions have arrived there by reverse peristalsis or common to each case : first, an inflammation the pulmonary vascular route of Keyting and of the gastrointestinal mucosa of a debilitated associates." It can be assumed that if bacteria destructive nature, and second, a sudden in-

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crease in the intraluminal pressure of the grams. After a period of 48 to 72 hours of air in the stomach and lungs from severe well-being following birth, there develop de- coughing or vomiting, or from insufflation layed gastric emptying, bile-tinged emesis and for instrumentation or intubation. gastric residue, and mild to severe abdominal distention which simulates neonatal agang- Conclusion lionosis. There is an associated infection of Emphysematous gastritis and phlegmonous gram-negative enteric organisms. The radio- gastritis are similar in their clinical presenta- graphic findings demonstrate air intramurally tion. An infection is present in both, there is in the gastrointestinal tract. When air has no history of any instrumentation, in both been demonstrated within the stomach wall the white blood cell count (WBC) is elevated, the mortality rate has been 100 per cent. and the temperature ranges from 103 to 105 F. In non-bacterial gastric emphysema there The onset of the symptoms is sudden. The is an absence of infection. The WBC is within differential diagnosis between phlegmonous normal limits, and the temperature may gastritis and emphysematous gastritis is range from 98.6 to 103 F. The onset of this made solely by the demonstration of air within condition is sudden. There is no history of the stomach wall in the latter condition. The instrumentation. A bullous pulmonary emphy- mortality rate of phlegmonous gastritis is sema is always present. Air enters the stomach 90 per cent, 13,14 while that of emphysematous wall primarily as the result of spontaneous gastritis is 66 per cent. rupture of the thin and weak surface of the In pneumatosis cystoides intestinalis an pleura and the lung adherent to the areolar infection may or may not be present. There is tissue in the paraesophageal area. This con- no history of instrumentation, the WBC is dition has never been demonstrated radio- normal, and the temperature ranges from graphically, and has a 100 per cent mortality 98.6 to 103 F. The onset of this condition is rate. insidious, with the patient asymptomatic. The In gangrene of the stomach wall the clinical radiographic findings demonstrate air within findings are caused by a massive infarction of the gastrointestinal wall. The mortality rate the gastrointestinal tract with thrombosis of of pneumatosis cystoides intestinalis of the the celiac axis artery. This condition develops gastric wall is 33 per cent with two deaths after colectomy. It is sudden in onset. Air has being reported, which occurred in 190416 and been shown to lie intramurally in the gastro- 1912.16 intestinal tract on radiographic films. The In gastric emphysema the clinical findings mortality rate in this condition is also 100 are the absence of infection and the history per cent. of an instrumentation. The WBC is normal In the evaluation of the various entities and the temperature is 98.6 F. The onset of known to cause air in the stomach wall, the symptoms is sudden. Radiographic findings nomenclature leaves much to be desired. Each demonstrate air within the stomach wall. case gave evidence of inflammation of the There has been no reported mortality associ- gastrointestinal mucosa of a debilitated des- ated with this condition. tructive nature, and a sudden increase in Necrotizing enterocolitis is usually seen in intraluminal pressure of the air in the gastro- infants with a birth weight of under 1,500 intestinal and pulmonary systems. This in-

746/98 crease was caused by severe cough, vomiting, tinalis has a mortality rate of 33 per cent. instrumentation, or intubation. Therefore, I There has been no mortality reported in would suggest the following classifications for gastric emphysema when demonstrated radio- diagnosis of air in the stomach wall. graphically. Pneumatosis cystoides intestinalis: 1. Gastrointestinal ulceration or obstruc- Summary tion demonstrated The radiologic sign of air in the stomach wall Emphysematous gastritis: is observed in six conditions. A review of 1. Acute infectious process of gastric twenty-four cases reported in the literature mucosa and a case of pneumatosis cystoides intesti- Necrotizing enterocolitis: nalis gastrica are presented. Criteria for 1. Infants, usually without surgery classification of air in the stomach wall are 2. Adults, with or without abdominal offered with the case presented being a classic surgery (gangrene) example of pneumatosis cystoides intestinalis Gastric emphysema or intestinal emphy- as judged by these criteria. sema: The high incidence of mortality associated 1. With instrumentation with these diseases demands early recogni- 2. Without instrumentation, associated tion of the radiologic sign of air in the stom- pulmonary disease ach wall. A knowledge of the mechanisms pro- Air in the stomach wall is indeed a rare ducing this sign is essential in order to finding, but it can be demonstrated radio- establish correct and prompt treatment. graphically. It has been found in patients as early as 36 hours of life and as late as 83 Addendum years of age. The ratio of occurrence of males Since the original writing of this paper three to females is 3:1. Six clinical entities have additional cases of air in the stomach wall been recognized in which air within the have been reported in the medical literature. stomach wall has been demonstrated. Emphy- Two cases in men, aged 44 and 61 years, oc- sematous gastritis 1,14,17-20 and gastric emphy- curred 1 month and 14 days respectively after sema21-25 have been reported six times, pneu- gastric surgery. Each had nasogastric cath- matosis cystoides intestinalis 9,15,16,26,27 five eter intubation, radiographic verification of times, non-bacterial gastric emphysemall,12 air in the stomach wall for 22 and 15 days, four times, necrotizing enterocolitis 3 twice, and necrotic casts of the stomach; each sur- and gangrene of the stomach28 once. vived the condition, reported as emphyse- It is of vital importance to recognize the matous gastritis.29 radiologic signs of air in the stomach wall Another case reported as emphysematous because of the high mortality rate associated gastritis occurred in a woman, aged 44 years, with five of the six clinical entities reported. after the ingestion of 23 per cent hydrochloric Nonbacterial gastric emphysema, necrotizing acid. This patient also had nasogastric cathe- enterocolitis, and gangrene of the stomach ter intubation. Radiographic evidence was have a mortality rate of 100 per cent. Emphy- recorded on the thirteenth day after the on- sematous gastritis has a mortality rate of 66 set. This patient also lived.30 per cent, and pneumatosis cystoides intes- These additional cases enhance the impor-

Journal AOA/vol. 66, March 1967 747/99 Mr in the stomach wall

tance of early recognition of this radiographic 24. Lumsden, K.: Radiological demonstration of gas in the stomach wall. Brit J Radiol 29:596-600, Nov 56 finding in order to institute the proper treat- 25. Myhre. J., and Wilson, J. A.: Study on occurrence of pneumo- ment. after gastroscopy and observance of interstitial emphy- sema of stomach. Gastroenterology 11 :115-9, Jul 48 26. Druckmann, A., et al.: Pneumatosis of the intestines. Amer J Roentgen 86:911-9, Nov 61 27. Elliott, G. B., and Elliott, K. A.: The roentgenologic pathology of so-called pneumatosis cystoides intestinalis. Amer J Roentgen 1. Henry. G. W.: Emphysematous gastritis. Amer J Roentgen 89:720-9. Apr 63 68:15-8, Jul 52 28. Dassel, P. M.: Roentgen demonstration of gangrene of the 2. Stiennon, A.: Pneumatosis intestinalis in newborn. Amer J stomach and intestine. A late finding in infarction of the gastro- Dis Child 81:651-63, May 51 intestinal tract. Amer J Roentgen 91:819-25, Apr 64 3. Berdon, W. E., et al. Necrotizing enterocolitis in the premature 29. Gonzales, L. L.. et al.: Emphysematous gastritis. Surg Gynec infant. Radiology 83:879-87, Nov 64 Obstet 116:79-87, Jan 63 4. Marten, L.: Personal communication 30. Han, S. Y.. Co, lins. L. C., and Petrany, Z.: Emphysematous 5. Hicks, M. C., and Kalmon, E. H.. Jr.: Congenital diaphragm of gastritis. JAMA 192:914-6, 7 Jun 65 the descending duodenum, radiographic demonstration of such a Alford, J. E., Galletti, G., and Culver, G. J.: Pneumatosis cys- lesion. Radiology 80:946-8, Jun 63 toides intestinalis. Amer J Surg 92:648-56, Nov 56 6. Madden. J. L., and McCann, W. J.: Collective review; con- Benson, R. E., and Raitt, G. P.: Pneumatosis cystoides intes- genital diaphragmatic occlusions of the duodenum, with a report tinalis with report of a case. Ann Surg 144:907-12, Nov 56 or 3 cases. Int Abstr Surg 103:1-15. 1956 Botsford. T. W., and Krakower, C.: Pneumatosis of the intestine 7. Tung, P. C.. and Ng S. K.: Gas cysts of intestines. Chin Med in infancy. J Pediat 13:185-94, Aug 38 J 47:1-14, Jan 33 Briggs, G. W., Sifre, R. A., and Overholt, E. L.: Pneumatosis 8. Jackson, J. A.: Gas cysts of the intestine. Surg Gynec Obstet cystoides intestinalis: Report of case. Ann Intern Med 40:618-26, 71:675-8, Nov 40 Mar 54 9. Keyting, W. S., et al.: Pneumatosis intestinalis: A new con- Dale, W. A., and Pearse. H. E.: Gas cysts of the intestines; re- cept. Radiology 76:733-41, May 61 port of two cases. Surg Gynec Obstet 90:215-20, Feb 50 10. Doub, H. P.. and Shea. J. J.: Pneumatosis cystoides intes- Felson, B.: Personal communication tinalis. JAMA 172:1238-42, 19 Mar 60 Glidden, S. A., and Stauffer, H. M.: Pneumatosis cystoides in- 11. Plachta, A., and Speer, F. D.: Nonbacterial gastric emphy- testinalis in an adult; preoperative roentgen diagnosis. Radiology sema: Review of literature and report of case. Amer J Gastroen- 60 :822-4, Jun 53 terol 28:460-5, Oct 57 Koss, L. G.: Abdominal gas cysts (pneumatosis cystoides intesti- 12. Plachta, A.. and Speer, F. D.: Mechanism of nonbacterial norum hominis) ; analysis with report of a case and critical review gastric emphysema. Gastroenterology 40:248-52, Feb 61 of the literature. AMA Arch Path 53:523-49, Jun 52 13. Miller, B., and Nushan, H.: Phlegmonous gastritis. Amer J Kushlan, S. D.: Pneumatosis cystoides intestinalis. Report of a Roentgen 67:781-4, May 52 case mimicking the with x-ray diagnosis 14. Welch. C. E., and Jones, C. M.: Emphysematous gastritis. N and resolution. JAMA 179:699-702, 3 Mar 62 Eng J Med 217 :983-5, 25 Dec 47 Lerner, H. H., and Gazin, A. I.: Pneumatosis intestinalis; its 15. Maass, H.: Demonstration eines prtiparates von Emphysern des roentgenologic diagnosis. Amer J Roentgen 56:464-9, Oct 46 grosses Netzes. Berlin KIM Wschr 41:401. 1904 MacKenzie, E. P.: Pneumatosis intestinalis; review of the litera- 16. Muller, P.: Ein Fall von muskularer Pylorusstenose bei einem ture with report of 13 cases. Pediatrics 7:537-49, Apr 51 Saugling mit melanaartigem Erbrechen and akuter Pneumatosis Miller. R. E.: Perforated viscus in infants: A new roentgen sign. cystoides des Magens. Inaugural dissertation, Otto Kindt, Giessen, Radiology 74:65-7, Jan 60 1912 MuMhed, Z., and Evans, J. A.: Gas cysts of the intestine 17, Farfel, B., and Eichhorn, R. D.: Emphysematous gastritis. (pneumatosis intestinalis). Surg Gynec Obstet 107:151:60, Aug 58 Amer J Gastroenterol 25:125-30, Feb 56 Olson, J. D.: Pneumatosis cystoides intestinalis; report of a case. 18. Fraenkel, E.: Ober einen Fall von Gastritis acute emphy- AMA Arch Surg 68:899-906. Jun 54 sematosa wahrscheinlich mykotishcen Ursprungs. Arch Path Anat 118:526-35, 1889 Ramos, A. J., and Powers, W. E.: Pneumatosis cystoides in- testinalis. Amer J Roentgen 77:678-83. Apr 57 19. Morton, J. J., and Stabins, S. J.: Phlegmonous gastritis of Bacillus aerogencs capsulatus (B. welchii) origin. Ann Surg Schorr, S.: Small-intestinal intramural air. Radiology 81:285-7, 87:848-54, Jun 28 Aug 63 20. Weens, H. S.: Emphysematous gastritis. Amer J Roentgen 55:588-93, May 46 21. Canceltno, J. J., Jr.: Interstitial gastric emphysema with re- port of a case. Radiology 63:81-3, Jul 54 This paper, written during Dr. Landis residency in the Depart- 22. Chamberlin, D. T.: following gastroscopy ment of Radiology, Grandview Hospital, Dayton, Ohio. of which apparently without perforation; report of a case. N Eng J Med Dr. Wesley V. Boudette is chairman, was accepted by the Ameri- 237:843-5, 4 Dec 47 can Osteopathic Board of Radiology in partial fulfillment of the 23. Fierst, S. M.. Robinson, H. M., and Lasagna, L.: Interstitial requirements for certification. gastric emphysema following gastroscopy; its relation to the syn- drome of pneumoperitoneum and generalized emphysema with no Dr. Landis, Detroit Osteopathic Hospital, 12523 Third Ave., De- evident perforation. Ann Intern Med 34:1202-12, May 51 troit, 48203.

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