Not All Gastric Air Is Equal: A Case Report Highlighting the Difficulty in Distinguishing Between Benign and Lethal Gastric Pneumatosis.

Gastric pneumatosis is a rare radiologic finding characterized by intramural gas within the gastric wall and includes two entities, gastric emphysema (GE) and emphysematous gastritis (EG). GE is typically benign and noninfectious, whereas EG results from invasion by gas-forming organisms and carries high mortality. Distinguishing between them can be challenging, particularly in critically ill patients. A 34-year-old man with autism spectrum disorder, severe protein-calorie malnutrition, and percutaneous endoscopic gastrostomy (PEG) dependence presented in shock following out-of-hospital cardiopulmonary arrest requiring prolonged resuscitation. CT imaging demonstrated right lower lobe pneumonia and gastric pneumatosis remote from the PEG site. He had no abdominal symptoms. Esophagogastroduodenoscopy revealed intact gastric mucosa without ischemia or necrosis. Blood cultures grew pan-susceptible Escherichia coli. With supportive care and antibiotics, he rapidly stabilized, and repeat imaging within 48 hours showed complete resolution. Despite bacteremia and shock, preserved mucosal integrity and rapid radiographic improvement supported gastric emphysema, illustrating the importance of integrating clinical, radiographic, and endoscopic findings to guide management and avoid unnecessary surgery.