RESUMEN
Emphysematous gastritis is a rare entity that has not much literature available. It is known to manifest as a diffused wall inflammation and air within the wall of the stomach and has been associated with gas-forming organisms. We present a complex case of a middle-aged woman with a previous history of fulminant Clostridium difficile complicated with colectomy and diverting colostomy. She was admitted due to diabetic ketoacidosis, later complicated with worsening abdominal pain, and a CT scan of the abdomen and pelvis without contrast revealed findings consistent with ischemic bowel, severe pneumatosis intestinalis, and extensive portal venous gas. A stomach biopsy revealed hemorrhagic necrosis; a Gomori methenamine silver stain was compatible with fungal organisms, Candida species, correlating with Candida emphysematous gastritis. This case highlights the importance of early diagnosis of this syndrome in order to provide appropriate management, and early identification, to improve survival.
RESUMEN
BACKGROUND: Surgical stabilization of rib fractures (SSRF) has gained increasing interest over the past decade, yet few candidates who could benefit from SSRF undergo operative management. We conducted an international survey of institutional SSRF guidelines comparing congruence between practice and contemporary evidence. We hypothesized that few guidelines reflect comprehensive evidence to facilitate standardized patient selection, operation, and postoperative management. METHODS: A request for institutional rib fracture guidelines was distributed from the Chest Wall Injury Society. Surgical stabilization of rib fractures-specific guideline contents were extracted using a priori-designed extraction sheets and compared against 28 SSRF evidence-based recommendations outlined by a panel of 14 international experts. Fisher's exact test compared the proportion of strong and weak evidence-based recommendations specified within a majority of institutional guidelines to evaluate whether strength of evidence is associated with implementation. RESULTS: A total of 36 institutions from 3 countries submitted institutional rib fracture management guidelines, among which 30 had SSRF-specific guidance. Twenty-eight guidelines (93%) listed at least one injury pattern criteria as an indication for SSRF, while 22 (73%) listed pain and 21 (70%) listed impaired respiratory function as other indications. Quantitative pain and respiratory function impairment thresholds that warrant SSRF varied across institutions. Few guidelines specified nonacute indications for SSRF or perioperative considerations. Seven guidelines (23%) detailed postoperative management but recommended timing and interval for follow-up varied. Overall, only 3 of the 28 evidence-based SSRF recommendations were specified within a majority of institutional practice guidelines. There was no statistically significant association ( p = 0.99) between the strength of recommendation and implementation within institutional guidelines. CONCLUSION: Institutional SSRF guidelines do not reflect the totality of evidence available in contemporary literature. Guidelines are especially important for emerging interventions to ensure standardized care delivery and minimize low-value care. Consensus effort is needed to facilitate adoption and dissemination of evidence-based SSRF practices. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
