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 radiologic sign 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 vomiting. 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 pneumatosis 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 gastritis. 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 duodenum 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 small intestine, 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 abdomen 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 esophagus 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 esophagitis. (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. Journal AOA/vol. 66, March 1967 741/93 Air in the stomach wall 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 cyst-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.