Keywords

EUS, EUS-guided fine needle aspiration, suppurative gastritis.

Introduction

A 71-year-old man presented with a 10-day history of abdominal pain, fatigue, nausea, anorexia, and an 8-10 pound weight loss in the absence of fever. The final diagnosis was a gastric wall abscess.

Methods for Image Capture/Processing

The Pentax linear array echoendoscope EG-3630U with Hitachi 6000 processor at 5MHz was used during this procedure.

Case/Body

The patient is a 71-year-old white male who presented with a chief complaint of abdominal pain for 10 days in association with fatigue, nausea, anorexia, and an 8-10 pound weight loss. He denied fever, rigors, or diarrhea.

He initially presented with acute onset of abdominal pain following several bursts of sneezing when he went outdoors and was exposed to environmental allergens in the form of grass cuttings. The pain came on suddenly after he sneezed and persisted through the night. In retrospect, he reported feeling somewhat fatigued approximately one to two weeks before, and had been treated with oral antibiotics for a recent bronchitis.

Figure 1

He presented to a local emergency department approximately 24 hours after the onset of his abdominal pain. Upon evaluation, he was found to have a white count of 20,000/mm3, a hematocrit of 30% (baseline was 36%), and a platelet count of 650,000/mm3. He underwent an abdominal CT scan, which demonstrated a 6 cm hypodense, irregular fluid-filled mass around the stomach (Figure 1). The CT scan was performed without IV contrast because of a renal insufficiency. He underwent an upper endoscopy, which demonstrated normal mucosa but an extrinsic compression along the greater curvature of the stomach. Mucosa forceps biopsies were negative. He was subsequently referred to the Massachusetts General Hospital (Boston, MA) for further evaluation.

His past medical history is notable for renal cell carcinoma status post right nephrectomy in 1986, coronary artery disease status post myocardial infarction x2, status post percutaneous balloon angioplasty with stenting x4, hypertension, and bilateral cataracts. He had no known drug allergies. He was a non-smoker and used alcohol rarely. He was employed as a psychiatrist. His family history was unremarkable.

On physical examination, he was a well-appearing white male in no acute distress, appearing mildly pale. He was anciteric, with a dry oropharynx. His chest was clear to auscultation bilaterally. He had a regular rate and rhythm, without murmurs, rubs, or gallops. There were no palpable abdominal masses and no Courvoisier’s or Murphy’s signs. He had a midline incision from his prior nephrectomy. There was no ascites or hepatosplenomegaly. There was no costovertebral angle tenderness. There was no evidence of peripheral edema or rashes. He was awake, alert, and oriented.

Diagnostic Evaluation

EUS and EUS-guided fine needle aspiration were performed on the first day of his hospitalization. Initial standard upper endoscopy demonstrated mild distal esophagitis and a normal duodenum. There was clear evidence of an extrinsic compression along the greater curvature of stomach with a small surface ulceration (Figure 2). Using the linear echoendoscope (Pentax linear array echoendoscope EG-3630U with Hitachi 6000 processor at 5MHz), a circumscribed, 6 cm x 5 cm submucosal mass was identified along the greater curvature (Figure 3). The lesion was characterized as a contained fluid collection with internal debris. Note was also made of two gallbladder stones and sludge in distended gallbladder. The gallbladder was noted to be in proximity to the gastric wall collection. The pancreas and left lobe of the liver were unremarkable. A 25-gauge needle was used to perform fine needle aspiration of the gallbladder, which demonstrated clear, green, uninfected-appearing bile. Rapid cytology demonstrated no evidence of neutrophils (Figure 4). We then used a 22-gauge needle to perform fine needle aspiration of the perigastric collection. Aspirated fluid was purulent in appearance, and rapid cytology clearly demonstrated abundant polymorphonuclear cells consistent with an abscess. Attempts were made to lavage the collection with saline, but because of the size of the collection, it was unable to be completely drained.

Figure 2	Figure 3	Figure 4

A follow-up abdominal and pelvic CT scan demonstrated two fluid collections (5 cm and 2 cm) in the distal stomach gastric wall. The gallbladder was notable for stones, and there did not appear to be any evidence of a contiguous process with the gastric wall collections.

The fluid culture from EUS-guided fine needle aspiration grew out multiple organisms including Escherichia coli, Klebsiella pneumoniae, Haemophilus parainfluenzae, and Lactobacillus species. Blood cultures were negative.

Treatment

Figure 5

The patient was placed on broad-spectrum antibiotics, including intravenous ampicillin, gentamicin, and metronidazole. He underwent percutaneous drainage of the abscess by Interventional Radiology. A trans-abdominal ultrasound–guided technique was used to access the gastric wall collections, and 200 cc of purulent material was obtained. An 8-Fr Dawson-Mueller drainage catheter was then inserted into the collection (Figure 5). Surgical management was deferred in this patient due to his underlying comorbid cardiovascular disease.

The patient underwent further evaluation with drainage catheter tube injection and barium enema to evaluate the possibility that the abscess developed in the setting of a communication with the colon. However, none of the studies performed demonstrated a bowel communication. After two weeks antibiotic treatment and percutaneous drainage, the abscess resolved and he recovered uneventfully.

Discussion

In summary, this is a case of a 70-year-old man who presented with abdominal pain, fatigue, anorexia, and weight loss who was found to have suppurative gastritis manifest as a 6 cm x 5 cm gastric wall abscess (polymicrobial) diagnosed by EUS and EUS-guided fine needle aspiration.

Suppurative gastritis is a rare entity, with approximately 500 cases reported in the literature. It is widely accepted that stomach is relatively protected from infection in the setting of an enhanced vascular supply and the antimicrobial environment provided by gastric acidity. Two types of suppurative gastritis have been described - a diffuse or phlegmonous variant and the more common, localized suppurative gastritis.

Suppurative gastritis may develop from either contiguous spread of infection or from hematogenous dissemination. There have reports of contiguous extension of infection into the gastric wall secondary to pancreatitis, cholecystitis, appendicitis, and diverticulitis. In addition, infection may arise from foreign body ingestion (fish bones), ectopic pancreas tissue inflammation, endoscopic biopsies, and from gastric surgery. There have been reports of superinfection of gastric wall neoplasms including carcinomas and leimyosarcomas. Hematogenous spread to the stomach has been described in the setting of endocarditis, pneumonia, osteomyelitis, and erysipelas. Patient-related risk factors for the development of suppurative gastritis include alcoholism, older age, diabetes mellitus, hypochlorhydria or achlorhydria, and immunosuppression.

In most cases, epigastric abdominal pain and nausea dominate the clinical picture. Fevers and rigors found may also be seen, but as in this case, may not be present in certain patient populations (elderly, immunosuppressed, diabetics). Unusual clinical presentations including purulent emesis and Deininger’s sign (decreased abdominal pain on changing from the supine to sitting position). Laboratory studies usually demonstrate leukocytosis with a left shift. Changes in acute phase markers (elevation in C-reactive protein and erythrocyte sedimentation rate; decrease in albumin) may also be seen.

The most common appearance of a gastric wall abscess is a submucosal tumor. The endoscopic appearance is variable but may include diffuse gastric erythema and bogginess, or, as in this case, focal extrinsic compression. Case reports have also described focal ulceration with expression of purulent debris into the gastric lumen. Most lesions have been characterized by cross sectional imaging utilizing computed tomography. These may demonstrate diffuse or focal gastric wall thickening with or without a focal fluid collection. Computed tomography also provides information of extension from or to adjacent abdominal viscera and assists with surgical or radiologic drainage procedures. The most common organisms seen in gastric wall abscess include Streptococcus sp., Staphlyococcus sp., Escherichia coli, Haemophilus influenzae, Proteus sp., and Clostridium sp. As in this case, polymicrobial collections may also be seen.

Endoscopic ultrasound provides a unique imaging modality for evaluating the gastric wall. Both radial and curved linear array EUS provide excellent visualization of the layers of the gastric wall. EUS has been used to evaluate gastric wall abscesses and typical features include a heterogeneic mass often with solid and cystic components. The mass usually is hypoechoic in appearance and may originate from the submucosa or muscularis propria layers. The differential diagnosis includes gastrointestinal stromal tumors, leiomyomas/ leimyosarcomas, hematomas, intramural varices, metastatic deposits, neurofibromas, and lipomas. Some authors have suggested that gastric wall abscesses may exhibit a characteristic Doppler pattern with a enhanced vasculature around the periphery of the lesion. As in this case, EUS-guided fine needle aspiration may be used to obtain tissue (solid and liquid) for evaluation, including microbiology.

Left untreated, both variants of suppurative gastritis may progress to peritonitis and death from sepsis. Mortality rates from suppurative gastritis have declined from over 90% in the pre-antibiotic era to 64% since the inception of antibiotics. Although surgery is definitive therapy, many patients will improve on a combination of broad antibiotics and drainage. Drainage may come in the form of percutaneous (catheter-guided) techniques or endoscopically through use of a needle knife.

In summary, suppurative gastritis is an uncommon clinical entity which may lead to peritonitis and death in patients with delayed diagnosis and treatment. EUS may provide an additional diagnostic tool in the evaluation of patients with suspected gastric wall abscesses and can lead to early and definitive treatment.

References


1. Bodnar Z, Buban T, Varvolgyi. Submucosal tumor-like gastric wall abscesses. Gastrointest Endosc 2004; 59:599. <Related link>

2. Chen CH, Yang CC, Yeh YH. Gastric wall abscess presenting as a submucosal tumor: Case report. Gastrointest Endosc 2003; 57:959. <Related link>

3. Iwakiri Y, Kabemura T, Yasuda D, Okabe H, Soejima A, Miyagahara T, et al. A case of acute phlegmonous gastritis successfully treated with antibiotics. J Clin Gastroenterol 1999;28:175. <Related link>

4. Kang BC, Kim KW, Lee SW, Kim JH. Gastric wall abscess: imaging diagnosis and endoscopic treatment.J Comput Assist Tomogr 1998;22;673. <Related link>

5. Seidel RH, Burdick JS. Gastric leiomyosarcoma presenting as a gastric wall abscess. Am J Gastroenterol 1998;93:2241. <Related link>

6. Will U, Masri R, Bosseckert H, Knopke A, Schonlebe J, Justus J. Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment. Endoscopy 1998;30:432. <Related link>

7. Lantz PE, Westerman EL, Seifert RW. Gastric wall abscess drained at endoscopy. Gastrointest Endosc 1989;35:272. <Related link>

8. Lifton LJ, Schlossberg D. Phlegmonous gastritis after endoscopic polypectomy. Ann Intern Med 1982;97:373. <Related link>

9. Murphy JF, Graham DY, Frankel NB, Spjut H. Intramural gastric abscess. Am J Surg 1976;131:618. <Related link>

10. Miller AI, Smith B, Rogers AI. Phlegmonous gastritis. Gastroenterol 1975;68:231.
<Related link>