Emphysematous gastritis with extensive portal venous gas and endoscopic mucosal necrosis: gastric preservation despite an alarming presentation.

Emphysematous gastritis (EG) is a rare, potentially life-threatening condition. Extensive gastric pneumatosis and portal venous gas may suggest irreversible ischemia, although radiological severity and mucosal injury do not necessarily indicate transmural necrosis. A 70-year-old man presented with acute epigastric pain and vomiting. Computed tomography (CT) demonstrated extensive gastric and duodenal pneumatosis with portomesenteric venous gas but patent visceral arteries. Immediately after CT, he developed cardiac arrest, with return of spontaneous circulation after approximately 14 min. Emergency laparoscopy showed a viable stomach without perforation or transmural necrosis, whereas intraoperative endoscopy demonstrated extensive necrotic-appearing gastric mucosa. Gastrectomy was therefore avoided. Follow-up CT 4 days later showed complete resolution of pneumatosis and portomesenteric venous gas. The patient subsequently died from post-anoxic neurological injury and multiorgan failure. Surgical exploration and gastric resection should remain distinct decisions in severe EG, integrating imaging, endoscopy, and direct assessment of gastric viability.