This case report reviews a 75-year-old male with several comorbidities who presented with acute encephalopathy and sepsis in the setting of COVID-19 pneumonia, who was noted to have significant gaseous distention of the stomach, emphysematous gastritis (EG), and severe stenosis of the celiac trunk on initial CT imaging. He was treated with empiric IV antibiotics, including ceftriaxone and metronidazole, which were changed to intravenous piperacillin-tazobactam after 24 hours. After being evaluated by surgery and gastroenterology, it was determined that risks outweighed the benefits of EGD and surgical intervention as the patient had a labile hemodynamic status. After extensive goals of care discussions with the patient’s family, he was transitioned to comfort measures only on day 4 of admission and ultimately passed the same day due to cardiopulmonary arrest. EG is often diagnosed late in its course and is associated with extremely high mortality, even with surgical intervention. Evidence from recent case series suggests increasing success with conservative management in selected patients; there are no formal guidelines.

Downhill esophageal varices (DEV) are rare vascular abnormalities of the proximal esophagus, commonly caused by superior vena cava obstruction. We report a 75-year-old man who presented with intermittent dysphagia and globus sensation, in whom endoscopy demonstrated large proximal esophageal varices. Extensive evaluation excluded portal hypertension and cross-sectional imaging, and venography showed a patent superior vena cava and inferior vena cava but demonstrated right internal jugular vein occlusion with possible azygos system compression. These findings were considered remote and insufficient to explain the extensive proximal varices, which were ultimately classified as idiopathic DEV. This atypical presentation underscores the diagnostic challenges of DEV and the need for heightened clinical awareness of this rare entity.