Bubble Trouble: A Tale of Two Cases of Gastric Pneumatosis—Emphysematous Gastritis Versus Gastric Emphysema

Gastric pneumatosis is a rare radiologic finding that encompasses two clinically distinct entities with markedly different prognoses: emphysematous gastritis (EG), a potentially fatal infectious process, and gastric emphysema (GE), a typically benign noninfectious condition. There is a paucity of literature that differentiates these two distinct entities. Prompt differentiation between these entities is critical, as management strategies and outcomes vary substantially. We present two contrasting cases of gastric pneumatosis successfully managed conservatively. The first case involved an 82-year-old man presenting with abdominal pain, distension, leukocytosis, portal venous gas, and intramural gastric air concerning for EG. Given the absence of perforation or peritonitis, he was treated nonoperatively with bowel rest, nasogastric decompression, and broad-spectrum intravenous antibiotics, resulting in complete clinical recovery. The second case involved a 77-year-old woman with metastatic pancreatic adenocarcinoma complicated by malignant duodenal obstruction causing GE. Computed tomography demonstrated gastric pneumatosis without gastric wall thickening or systemic toxicity, favoring a benign etiology. She improved with conservative management and subsequent duodenal stent placement. These cases highlight the importance of integrating clinical presentation, laboratory findings, and imaging characteristics to distinguish EG from GE. Recognition of key differentiating features may facilitate timely diagnosis, guide appropriate therapy, and prevent unnecessary surgical intervention in carefully selected patients with gastric pneumatosis.