Emphysematous gastritis with portal venous gas: conservative management in a high-risk patient.

Emphysematous gastritis is a rare, often fatal condition characterized by gas within the gastric wall, usually in patients with significant comorbidities. We describe a 75-year-old man with incomplete tetraparesis, chronic respiratory failure and type 2 diabetes who presented with abdominal pain, vomiting and hematemesis. Initial computed tomography (CT) was reported as non-obstructive small-bowel dilatation with possible gallstone ileus, but subspecialty radiology review identified intramural gastric gas with portal venous gas consistent with emphysematous gastritis. He was managed non-operatively with nasogastric decompression, intravenous broad-spectrum antibiotics and proton-pump inhibition within a ward-based ceiling of care. Repeat CT on day 10 showed complete radiological resolution. Despite this, he later developed sepsis from a large necrotic pressure ulcer and died after a multidisciplinary decision for palliative care. This case supports conservative management in selected high-risk patients and emphasizes early, meticulous pressure-area assessment in immobile surgical admissions.