Geriatric Patient Successfully Managed With Conservative Therapy Despite Portal Venous Gas.

Intramural gastric air with concomitant portal venous gas is an uncommon radiographic finding that presents a significant diagnostic challenge. The primary differential diagnoses include gastric emphysema (GE), a generally benign and self-limiting condition, and emphysematous gastritis (EG), a rare but potentially fatal infectious process associated with high mortality rates. Although these conditions may appear similar on computed tomography (CT), they differ considerably in pathophysiology, clinical presentation, management, and prognosis. Accurate distinction between the two entities is essential to guide treatment decisions and avoid unnecessary surgical intervention. We present the case of a 96-year-old man with a history of chronic heart failure and hypertension who presented with a 24-hour history of nausea, vomiting, abdominal pain, and diarrhea following a meal. On admission, the patient was hemodynamically stable, afebrile, and without signs of peritonitis. Laboratory evaluation was notable only for acute kidney injury secondary to dehydration. CT imaging of the abdomen and pelvis demonstrated gastric distention, intramural gastric air, and significant portal venous gas, raising concern for both GE and EG. Despite concerning radiographic findings, the patient's benign clinical presentation favored gastric emphysema. He was managed conservatively with bowel rest, intravenous fluids, proton pump inhibitor therapy, broad-spectrum antibiotics, serial abdominal examinations, and close clinical observation. Throughout hospitalization, the patient remained clinically stable with progressive improvement in symptoms and no evidence of systemic toxicity or acute abdomen. Repeat CT imaging obtained on hospital day 3 demonstrated complete resolution of portal venous gas and near-complete resolution of gastric wall air. The patient tolerated diet advancement and was discharged home in stable condition. This case emphasizes the importance of correlating radiographic findings with the overall clinical presentation when evaluating gastric pneumatosis and portal venous gas. Careful clinical assessment and close monitoring may allow successful conservative management in appropriately selected patients while avoiding unnecessary operative intervention.