Surviving Emphysematous Gastritis after Hepatectomy

Emphysematous gastritis is a rare variant of phlegmonous gastritis due to invasion of stomach wall by gas-forming bacteria. It is characterised by abnormal presence of gas in the stomach by imaging, in association with clinical sepsis. Patients suffering from this condition usually present with an underlying pathology. We are reporting a middle-aged Chinese male with hepatitis B virus related hepatocellular carcinoma. He underwent partial hepatectomy and was diagnosed with emphysematous gastritis 4 days after index operation. Emergency laparotomy, including upper endoscopy, was performed. He was managed with antibiotics and discharged 18 days after second operation. This paper shows a review of the literature about the disease, with particular attention to pathology, clinical features, and management. 1. Case Report A 52-year-old man was known to have hepatitis B virus related cirrhosis. He was a nondrinker and otherwise enjoyed good past health. He had regular ultrasound screening of his liver. A 3？cm lesion was detected by screening ultrasound in the right lobe of liver. Subsequent contrast CT abdomen confirmed the presence of a 3？cm lesion in segment 6 with arterial enhancement and early portovenous washout (Figure 1) suggestive of hepatocellular carcinoma. His complete blood picture was normal. Serum bilirubin level was 24？ mol/L. The serum albumin level was 36？g/L. Open wedge resection of the liver tumour was performed. The operation lasted 4 hours, and blood loss was 200？mL. No blood transfusion was required perioperatively. Pringle maneuver was not performed throughout the procedure. A nasogastric tube was placed in the stomach for decompression. Amoxicillin/clavulanic acid 1.2？g and esomeprazole 40？mg were administered intravenously immediately before operation and were continued postoperatively. Histopathological examination confirmed well-differentiated hepatocellular carcinoma with closest resection margin 1？cm. Figure 1: Preoperative CT scan showing the hepatocellular carcinoma at segment 6. The stomach was unremarkable. No gas was noted in the portal vein. Nasogastric tube was removed on day 1 and diet resumed on the next day. However, patient complaint of shortness of breath, palpitations, and epigastric discomfort on post-operative day 4. Physical examination revealed tachycardia (130？bpm) and mild epigastric tenderness. Blood tests showed neutrophil predominant leukocytosis and bilirubin raised up to 45？ mol/L. Arterial blood gas showed metabolic acidosis (pH 7.24, 16？mmol/L and base excess ？6？mmol/L). Erect abdominal radiograph showed