Severe Diabetic Gastroparesis Masquerading as Emphysematous Gastritis and Surgical Abdomen.

A 66-year-old man with type 2 diabetes mellitus and known gastroparesis presented to the emergency department with fatigue, confusion, and hypoglycemia. During hospitalization, he developed worsening abdominal pain and distention. CT revealed marked gastric distention, extensive portal venous gas, and mesenteric air, raising concern for emphysematous gastritis, gastric outlet obstruction, or volvulus. Despite these alarming radiographic findings, the patient remained hemodynamically stable, with no peritoneal signs. Surgical consultation was obtained; however, given his clinical stability and history of gastroparesis, conservative management was pursued. Treatment included nasogastric decompression, IV fluids, and prokinetic therapy with metoclopramide and erythromycin. Within 48 hours, the patient demonstrated significant clinical and radiologic improvement, with resolution of portal venous gas and reduction in gastric distention. He was discharged on oral prokinetics and referred to a tertiary care center for ongoing gastroparesis management. This case highlights that severe diabetic gastroparesis can produce imaging findings that mimic life-threatening surgical emergencies. In hemodynamically stable patients with known motility disorders, recognition of this potential mimic is essential to avoid unnecessary surgical intervention and to guide appropriate conservative treatment.