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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 170-172

Incarcerated umbilical hernia associated with gastric pneumatosis

1 Department of Surgery, St. Luke's Hospital and Health Network; OPUS 12 Foundation, Inc., Bethlehem, PA, USA
2 OPUS 12 Foundation, Inc., Bethlehem, PA, USA
3 OPUS 12 Foundation, Inc., Bethlehem; Department of Surgery, Division of Traumatology and Surgical Critical Care, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
4 Department of Surgery, St. Luke's Hospital and Health Network, Bethlehem, PA, USA

Date of Web Publication21-Apr-2017

Correspondence Address:
Stanislaw P Stawicki
Department of Surgery, St. Luke's Hospital and Health Network, 801 Ostrum Street, Bethlehem, PA 18015
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_85_16

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Gastric pneumatosis is a well-recognized clinical entity that is described in the literature as either a subtype of pneumatosis cystoides intestinalis or gastric emphysema. Gastric pneumatosis may be due to a variety of causes, which are classically categorized as infectious or noninfectious in nature. We report a case of gastric pneumatosis and pneumoperitoneum associated with a bowel obstruction secondary to an incarcerated umbilical hernia. Literature about gastric pneumatosis was reviewed and the different classifications and etiologies briefly described. Knowledge of the different types and natural history of gastric pneumatosis can be helpful when deciding on surgical versus nonoperative management of patients with this condition.
The following core competencies are addressed in this article: Medical knowledge and patient care.
Republished with permission from: El Chaar M, Stawicki SP, Jenoff J, Estrada FP. Incarcerated umbilical hernia associated with gastric pneumatosis: A case report OPUS 12 Scientist. 2007;1(1):9-10.

Keywords: Case report, gastric pneumatosis, incarcerated hernia, pneumatosis cystoides intestinalis

How to cite this article:
El Chaar M, Stawicki SP, Jenoff J, Estrada FP. Incarcerated umbilical hernia associated with gastric pneumatosis. Int J Acad Med 2017;3, Suppl S1:170-2

How to cite this URL:
El Chaar M, Stawicki SP, Jenoff J, Estrada FP. Incarcerated umbilical hernia associated with gastric pneumatosis. Int J Acad Med [serial online] 2017 [cited 2023 Feb 3];3, Suppl S1:170-2. Available from: https://www.ijam-web.org/text.asp?2017/3/3/170/204967

  Introduction Top

Pneumatosis cystoides intestinalis (PCI) is an uncommon clinical entity characterized by submucosal and/or subserosal collections of gas within the gastrointestinal tract and its peritoneal attachments.[1] Gastric pneumatosis is traditionally classified as a variant of PCI.[2],[3] Gastric pneumatosis can be caused by gas-forming bacteria, severe gastritis, rupture of pulmonary bullae, and other conditions. We report an unusual case of gastric pneumatosis associated with an incarcerated umbilical hernia.

  Case Report Top

An 88-year-old woman presented to the emergency department complaining of 3-day history of diffuse abdominal pain, nausea, and vomiting. Her medical history included hypertension, coronary artery disease, congestive heart failure, gastroesophageal reflux disease, and osteoarthritis. Her previous surgical history included appendectomy and right total hip arthroplasty.

On physical examination, the patient had moderate abdominal distension and nonspecific tenderness, but no rebound or guarding. The patient was also noted to have an incarcerated umbilical hernia. Her temperature was 100.1°F, with a heart rate of 82 and blood pressure of 140/90 mmHg. Laboratory studies demonstrated an elevated white blood cell count (15,000/mm 3) and normal lactate level (1.9 mmol/L).

Computed tomographic (CT) scan of the abdomen and pelvis showed dilated proximal small bowel loops, gastric pneumatosis, and free intraperitoneal air [Figure 1]. The patient was taken for an emergent laparotomy. Upon exploration, there was intramural gas along the lesser and greater curvatures of the stomach. There was no evidence of gastric volvulus, gastric or duodenal perforation. Inspection of the lesser sac revealed no abnormalities. An incarcerated umbilical hernia was also reduced and repaired. The small bowel proximal to the hernia was moderately dilated. Postoperatively, the patient underwent upper endoscopy, which demonstrated diffuse gastritis.
Figure 1: Computed tomographic scan demonstrating gastric pneumatosis and intraperitoneal air. Note the dependent nature of the intramural gastric air

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  Discussion Top

PCI or cystic pneumatosis is a descriptive term denoting abnormal collections of intramural intestinal or gastric gas.[4],[5] These air-filled pseudocysts are located in the submucosa or the subserosa of the digestive tract and usually range from 0.5 cm to 2.0 cm in size. PCI can be either primary or secondary in nature.[2] The primary type, also known as “gastric emphysema,” is due to an infectious process at the site of the intramural air.[2],[6] In the secondary type, an underlying pathologic state or procedure-related trauma (perforated gastric ulcer, ruptured pulmonary bullae, neoplasm, nasogastric tube placement, and upper endoscopy) may be contributory.[2],[6]

Gastric pneumatosis was traditionally classified as a subtype of PCI. However, recent reports have reclassified these entities into either “gastric emphysema” or “cystic pneumatosis” because of their distinct associated radiographic and pathologic features.[2],[6] In cystic pneumatosis, the cysts are usually ovoid in shape and the gas pattern is cystic in nature.[3] In case of gastric emphysema, there are linear radiolucent streaks that are usually seen parallel to the border of the stomach and are separated from the lumen by an area of water density that is few millimeters in thickness.[3]

Numerous etiologies of gastric pneumatosis have been described in the literature.[1],[6],[7],[8],[9],[10] In general, these can be divided into either infectious or mechanical. Infectious gastric pneumatosis is usually caused by gas-forming bacteria. This is a relatively rare entity characterized by mucosal and submucosal inflammation and bacterial infiltration of most of the gastric wall layers on autopsy specimens.[6],[7],[8] These patients present with leukocytosis, high-grade fevers, and other signs and symptoms of sepsis. Infectious gastric emphysema carries a very poor prognosis, with an overall mortality rate as high as 60%–70%.[1],[6],[9],[10]

Gastric pneumatosis secondary to mechanical etiologies is far more common than the primary gastric emphysema. Here, causes include obstruction, trauma, rupture of pulmonary bullae, enteric tube placement, and upper endoscopic procedures.[1],[9],[10] In these cases, the intraluminal gas dissects into the gastric wall through a mucosal tear or defect. The tear usually results from increased intraluminal pressure secondary to an obstruction or as a direct result of trauma. The reported mortality in this group, although lower than mortality associated with gastric emphysema, is still high at 6%–41%.[6] While other authors describe gastric pneumatosis secondary to bowel or gastric outlet obstruction, gastric pneumatosis specifically associated with an incarcerated umbilical hernia has not been previously reported.

When approaching gastric pneumatosis due to mechanical causes, clinical judgment should be carefully applied when determining which patients need surgical exploration and which ones can be observed safely. Selective nonoperative management has been used successfully in the setting of secondary gastric pneumatosis.[6]

  Conclusions Top

Gastric pneumatosis is a relatively rare entity that can be due to either infectious or mechanical causes. We reported a case of pneumoperitoneum and gastric pneumatosis secondary to an incarcerated umbilical hernia with an associated bowel obstruction. While patients with primary (infectious) gastric emphysema warrant an emergent surgical exploration, carefully selected cases of secondary (mechanical) gastric pneumatosis may be observed clinically in the absence of other surgical indications.


Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Cordum NR, Dixon A, Campbell DR. Gastroduodenal pneumatosis: Endoscopic and histological findings. Am J Gastroenterol 1997;92:692-5.  Back to cited text no. 1
Kussin SZ, Henry C, Navarro C, Stenson W, Clain DJ. Gas within the wall of the stomach report of a case and review of the literature. Dig Dis Sci 1982;27:949-54.  Back to cited text no. 2
Scheidler J, Stäbler A, Kleber G, Neidhardt D. Computed tomography in pneumatosis intestinalis: Differential diagnosis and therapeutic consequences. Abdom Imaging 1995;20:523-8.  Back to cited text no. 3
Soon MS, Yen HH, Soon A, Lin OS. Endoscopic ultrasonographic appearance of gastric emphysema. World J Gastroenterol 2005;11:1719-21.  Back to cited text no. 4
Fischetti AJ, Saunders HM, Drobatz KJ. Pneumatosis in canine gastric dilatation-volvulus syndrome. Vet Radiol Ultrasound 2004;45:205-9.  Back to cited text no. 5
Taylor DR, Tung JY, Baffa JM, Shaffer SE, Blecker U. Gastric pneumatosis: A case report and review of the literature. International pediatrics. 2000;15(2):117-20.  Back to cited text no. 6
Yale CE, Balish E, Wu JP. The bacterial etiology of pneumatosis cystoides intestinalis. Arch Surg 1974;109:89-94.  Back to cited text no. 7
Gillon J, Tadesse K, Logan RF, Holt S, Sircus W. Breath hydrogen in pneumatosis cystoides intestinalis. Gut 1979;20:1008-11.  Back to cited text no. 8
Chintapalli KN. Gastric bezoar causing intramural pneumatosis. J Clin Gastroenterol 1994;18:264-5.  Back to cited text no. 9
Mandell GA, Finkelstein M. Gastric pneumatosis secondary to an intramural feeding catheter. Pediatr Radiol 1988;18:418-20.  Back to cited text no. 10


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