A Misplaced Pocket of Air: Intramural Gastric Air Most Consistent With Gastric Emphysema.

BACKGROUND: Gastric emphysema (GE), or gastric pneumatosis, is a rare, noninfectious cause of intramural gastric air that must be distinguished from emphysematous gastritis (EG), a highly lethal infectious entity. Despite similar radiographic appearances, these conditions differ substantially in etiology, clinical course, management, and prognosis. CASES: We report three hemodynamically stable patients with CT-confirmed intramural gastric air most consistent with GE. Two had associated portal venous gas. The cases occurred in distinct clinical contexts: infectious gastroenteritis with retching, transient midgut volvulus with obstructive gastric overdistension, and alcohol-related upper gastrointestinal bleeding with forceful vomiting and a Mallory-Weiss tear. Although early EG could not be excluded with absolute certainty, the absence of sustained systemic toxicity, peritonitis, endoscopic necrosis, or clinical deterioration supported conservative management. CONCLUSION: Intramural gastric air should be interpreted in clinical context rather than by CT appearance alone, particularly when portal venous gas or early antibiotic exposure complicates diagnostic certainty. Stable patients without systemic toxicity, peritonitis, endoscopic necrosis, or clinical deterioration may be managed conservatively with multidisciplinary input, while escalation should be reserved for suspected ischemia, perforation, sepsis, or clinical decline.