Emphysematous gastritis: a systematic review of reported cases exploring predictors of mortality

Introduction

Emphysematous gastritis (EG) is a rare and potentially fatal condition characterized by gas within the gastric wall due to infection by gas-forming bacteria (1). Unlike benign gastric emphysema (2), which occurs in the absence of infection and has a more favorable prognosis, EG is associated with a high mortality rate due to its aggressive nature and rapid progression (3,4). Despite advancements in diagnostic imaging and critical care, the condition remains poorly understood, with significant variability in clinical presentation, management strategies, and patient outcomes.

Timely interventions are critical for improving survival, particularly in high-risk populations, including immunocompromised patients or those with underlying conditions like diabetes mellitus, alcohol use, and recent chemotherapy exposure (5-8). Despite the increasing number of reported cases, EG remains poorly understood, with limited consensus on its optimal management (9). While computed tomography (CT) is the gold standard for diagnosing EG (10), the role of esophagogastroduodenoscopy (EGD) remains controversial due to concerns about iatrogenic gastric perforation (11-13). The treatment of EG primarily involves supportive care and broad-spectrum antibiotic therapy targeting polymicrobial infections (14). In more severe cases, interventions such as nasogastric decompression, total parenteral nutrition (TPN), and even surgical intervention may be required (15). However, the lack of knowledge has led to significant heterogeneity in reported management approaches and outcomes.

This systematic review aims to provide a comprehensive synthesis of the literature on EG, focusing on its epidemiology, clinical characteristics, diagnostic modalities, therapeutic strategies, and prognostic factors. It may assist in developing guidance that is urgently needed to improve patient outcomes for this debilitating condition. We present this article in accordance with the PRISMA reporting checklist (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-152/rc).

Methods

Data sources and search strategy

The protocol was registered on PROSPERO https://www.crd.york.ac.uk/prospero/ {Search ID: [CRD42025630471]}. A comprehensive search strategy was conducted across three electronic databases: PubMed, Embase, and Scopus. We searched publications from database inception to November 15, 2024. The keyword search strategy included “emphysematous gastritis”, “gastric pneumatosis”, “gas-forming gastritis”, and “pneumatosis of the stomach”. No restrictions were applied during the initial search strategy. However, studies were included for review based on predefined eligibility criteria, as described in the following section. The complete search strategies for each database are provided in Table S1; which details the database-specific query structures used for Case reports/series identification. Rayyan (rayyan.ai) was used to assist in title and abstract screening by enabling blinded independent review and conflict identification; however, all inclusion and exclusion decisions were made manually by the reviewers (S.S., S.A., and M.A.).

Article selection and eligibility

All identified papers were imported into Rayyan, and S.S. and S.A. conducted title screening; M.A. resolved disagreements. We included abstracts and manuscripts that reported on: (I) adults aged 18 years or older; (II) diagnoses of EG; and (III) data on demographics, clinical features, management interventions, and outcomes. Papers were excluded if they involved any of the following: (I) animal studies; (II) insufficient clinical details; (III) cases of asymptomatic (benign) gastric emphysema; (IV) included pediatric population (less than 18 years of age).

Data extraction

Data extraction was conducted using a standardized Excel spreadsheet by M.R., S.A., and N.A.; then cross-verified by M.A. and S.S.; extracted data encompassed demographics, clinical features, diagnostics, treatments, and outcomes. Variables included the year and country of publication, patient age and gender, clinical symptoms (vomiting, hematemesis, abdominal pain), and comorbidities (alcohol use, diabetes mellitus, chemotherapy exposure, and corrosive ingestions). Diagnostic data included CT imaging, microbiology testing, and EGD. Data on management strategies captured NG tube insertion, TPN, and surgical interventions. Outcome variables focused on complications like gastric perforation and death. Variables not reported within the original case reports were treated as missing without imputation. No assumptions were made about absent or unclear data. No automation tools were used for data extraction.

Study quality and bias assessment

The Joanna Briggs Institute (JBI) critical appraisal checklist for case reports was employed to evaluate the quality and methodological rigor of the included studies.

Statistical analysis

Data analysis was performed using Stata version 18.5. Continuous variables were summarized as means, while categorical variables were presented as proportions. Logistic regression analysis was applied to evaluate factors associated with mortality. The study used extracted patient-level data, while variables not reported in original publications were treated as missing. Categorical variables were converted into binary indicator variables (0/1) for logistic regression (e.g., presence of comorbidity, diagnostic modality, intervention). No additional data transformations or imputations were performed. Findings should be interpreted as hypothesis-generating rather than confirmatory

Results

Search result & study selection

A total of 2,318 articles were identified through a comprehensive search of three databases: PubMed (n=509), Scopus (n=600), and Embase (n=1,209). After removing 363 duplicate records prior to screening, 1,955 studies remained for screening based on their titles and abstracts. Of these, 1,468 records were excluded, and 487 reports were sought for retrieval. A total of 172 reports could not be retrieved, leaving 315 eligible for assessment. Among these, 134 reports were excluded due to insufficient clinical details or incorrect diagnosis (n=96), animal studies (n=16), and studies involving pediatric populations (n=23). Ultimately, 180 articles were included in the review, comprising 173 case reports and 7 case series (Figure S1), which illustrates the PRISMA-based study selection process.

Epidemiology and patient demographics

A total of 189 cases of EG were identified from the literature. The number of published cases has increased, with the highest recorded in 2020 (26 patients, of whom 10 died; Figure S2), demonstrating the temporal trend in reported cases and associated mortality. The United States accounted for most cases (n=97, 51%), followed by the United Kingdom (n=8), Japan (n=9), and Spain (n=7) (Table S2), which summarizes the geographic distribution of reported cases worldwide. The mean age of affected patients was 61.7 years (18–97 years), with a male predominance (62%). The most reported clinical symptoms included abdominal pain (78%), vomiting (60%), and hematemesis (24%). Key underlying comorbidities included diabetes mellitus (35%), alcohol use (7%), chemotherapy exposure (8%), and corrosive ingestion (4%) (Table S3; provides a comprehensive summary).

Diagnostic modalities

In 90% of cases, CT imaging confirmed the presence of gas within the gastric wall (Figure 1A). EGD was performed in 50% of cases, with some reports describing submucosal bubbles (Figure 1B,1C as an example). Endoscopic findings most frequently included ulcerations (36%) of cases, followed by ischemia or necrosis (33%), and mucosal erythema or edema (31%) (Figure S3). Microbiological cultures were positive in 48% of reported cases. Clostridium species were the most frequently identified among the isolated microorganisms, accounting for 41% of cases. Gram-negative Enterobacteriaceae species were detected in 23%, while Staphylococcus or Streptococcus species were identified in 18%. Polymicrobial infections were observed in 16%, and fungal infections were rare, detected in only 2% cases (Figure S4).

Figure 1 Imaging and endoscopic findings in emphysematous gastritis. (A) CT scan showing intramural air (arrowheads) in the posterior stomach wall and portal vein gas (arrow) characteristic of emphysematous gastritis. (B) Endoscopic image of an inflamed and necrotic gastric lesion in the fundus correlating with CT findings, which completely healed two months later following conservative management (C). Images reproduced with permission from Matsushima et al. (16). CT, computed tomography.

Treatment strategies

Management approaches varied widely across reported cases. Antibiotic therapy was the cornerstone of treatment, administered in 76% of cases. Supportive measures included NG decompression and TPN were reported in 27% & 11% respectively. Surgical intervention was needed in 28% of cases, often for complications such as gastric perforation, which happens in 20 (11%) patients (Table S3).

Mortality

The overall reported mortality rate for EG was 27% (n=50). Figure S2 illustrates the annual trend of reported deaths per case, demonstrating fluctuations over the years, with a notable increase in recent years. Multivariate regression analysis identified alcohol use [odds ratio (OR): 4.16, P=0.02] and chemotherapy exposure (OR: 5.60, P<0.01) and surgical intervention (OR: 2.10, P=0.04) as significant predictors of increased mortality. In contrast, EGD was associated with lower odds of mortality (OR: 0.44, P=0.02). Other variables, including age, gender, diabetes mellitus, corrosive ingestion, TPN, and NG tube insertion, were not significantly associated with mortality (Table S4).

Discussion

This systematic review, encompassing 189 EG cases, highlights the rising recognition of this rare but life-threatening condition. The mean age of affected patients was 62 years, with a male predominance (62%), consistent with prior findings reporting a male predominance and an age above 55 years (16-18). Abdominal pain and vomiting were the most common symptoms, and CT imaging was the diagnostic cornerstone, used in nearly 90% of cases. Overall mortality was high (27%), and key predictors of worse outcomes included alcohol use, chemotherapy exposure, and surgical intervention. EGD was performed in about half of all patients and was significantly associated with a lower odds of mortality (OR: 0.44, P=0.02) and gastric perforation (OR: 0.08, P<0.01), but this may reflect selection bias.

Our results align with earlier literature describing EG as a disease of older, often immunocompromised adults, with diabetes, alcohol use, corrosive ingestion, and chemotherapy being well-established risk factors (5-7,19-23). The proportion of diabetics in our cohort (35%) supports previous studies linking metabolic dysfunction to increased susceptibility to gas-forming bacterial infection (24). Interestingly, alcohol and corrosive ingestion, though present in fewer cases, were significant contributors to mucosal injury, facilitating bacterial invasion (20,21). Chemotherapy, identified in 15 patients, was strongly associated with mortality (OR: 5.60, P=0.003), likely due to associated immunosuppression (25).

CT imaging remains the gold standard for diagnosis (10), Consistent with our findings, Elnaggar et al. [2025] reported CT as the most effective diagnostic modality for detecting intramural gastric gas in EG (26). However, our findings support a complementary role for EGD in diagnosis and management. EGD can detect mucosal ischemia, ulceration, and necrosis that are not always evident on imaging (11,13). Contrary to previous concerns, our analysis suggests EGD may be safe when clinically indicated, potentially aiding in early diagnosis and even microbial sampling (12,27). Matsushima et al. previously proposed that EGD can distinguish benign gastric emphysema from EG, guiding the decision for surgical intervention (16). Moreover, when empirical antibiotic therapy fails, endoscopy-directed aspirates may help isolate rare pathogens, as reported in mucormycosis or Lactobacillus infections (24,27).

Treatment in most cases included broad-spectrum antibiotics and supportive care, consistent with recommendations from previous reviews (14,15,28). While surgical intervention was necessary in 28% of cases, its association with higher mortality (OR: 2.10, P=0.04) likely reflects disease severity as a confounder rather than surgical risk itself. TPN and nasogastric decompression were used in select patients, although neither was independently associated with mortality. Given the polymicrobial nature of the infection, as previously reported with Clostridium, Enterobacteriaceae, and Streptococci (1), empirical therapy should remain broad-spectrum, and culture results obtained in just 47% of cases should guide adjustments when feasible (12).

This study is not without limitations. First, the reliance on case reports and series introduces publication and selection bias, as more severe or unusual cases are disproportionately reported. Second, variability in clinical documentation (missing variables), misclassification and reporting standards led to heterogeneity, which limits the comparability of individual cases. Additionally, the retrospective nature of included studies restricts causal inference. Most cases originated from North America, particularly the U.S., limiting global generalizability. Nonetheless, this represents the most extensive synthesis to date on EG and identifies consistent trends in diagnosis, management, and outcomes. Limitations of the review process include the reliance on manual screening and extraction, which may introduce human error despite independent verification.

Conclusions

In conclusion, EG remains a serious clinical entity with a high mortality rate, particularly in patients with alcohol use, chemotherapy exposure, or those requiring surgery. While CT remains essential for initial diagnosis, our findings support the adjunctive role of EGD in diagnosis, risk stratification, and potentially reducing mortality. These results highlight the importance of early recognition, risk stratification, and prompt management. Future prospective studies are needed to develop standardized diagnostic criteria and management algorithms from gastroenterology & endoscopy standpoint to improve patient outcomes.

Acknowledgments

This work was previously presented as an abstract at Digestive Disease Week (DDW) in May 2025.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-152/rc

Peer Review File: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-152/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-152/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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