Phlegmonous Gastritis after Endoscopic Mucosal Resection

Abstract

IntroductionPhlegmonous gastritis is a rare complication of endoscopic pro− cedures, or may occur in the fetus [1]. Two cases have been re− ported: one followed India ink marking and the other followed polypectomy [2,3]. Several conditions can predispose to the de− velopment of phlegmonous gastritis, including conditions asso− ciated with reduced immune response, gastrointestinal bleeding, and abdominal surgery [4,5]. We encountered a case of phleg− monous gastritis and report it here because of its rarity. Case ReportA 68−year−old woman was transferred to the Department of In− ternal Medicine because of a gastric adenoma. Her vital signs in the endoscopy room were normal, and all her laboratory test re− sults were normal. Endoscopic examination before endoscopic polypectomy showed an elevated mass (0.7 cm 0.7 cm) at the lesser curvature of the antrum (Figure 1 a). We performed an en− doscopic mucosal resection. Eight hours later, she visited the emergency room because of epigastric pain and fever. She looked acutely ill; her blood pressure was 180/90 mm Hg, pulse 88 beats per minute, and body temperature 38.58 C. Her white blood cell count was 11890/mm 3 and her hemoglobin was 14.9 g/dl. No free air was seen on the chest radiograph.A thickened, edematous gastric wall, especially in the antral area, was found on endoscopy (Figure 1 b), but no ulceration or pus was seen. Abdominopelvic computed tomography revealed dif− fuse thickening of the gastric wall (Figure 1 c). We started anti− biotic treatment about 20 hours after the endoscopic mucosal re− section. On day 4 of her hospital stay, follow−up CT showed im− provement in the gastric−wall thickening and perigastric hazi− ness, and her symptoms were relieved. Enterococcus fecalis was cultured from her gastric secretions. Endoscopic biopsy showed histological evidence of acute and chronic gastritis. Antibiotic treatment was continued until day 14 and she was discharged on day 15.One week later, she developed epigastric pain and watery diar− rhea, accompanied by fever, and she visited the outpatient clinic. She was readmitted and given combined antibiotic treatment. Despite this, her fever persisted. Moreover, she had fluctuating Abstract Phlegmonous gastritis, or acute suppurative gastritis, is a rare, life−threatening condition which is characterized by purulent necrosis and thickening of the gastric wall. A combination of gastrectomy and antibiotic therapy is an effective treatment. We report a rare case of phlegmonous gastritis occurring after endoscopic mucosal resection. The patient was treated initially with antibiotic therapy but eventually required surgery. Case Report 490Downloaded by: Karolinska Institutet. Copyrighted material.

Phlegmonous Gastritis in a 32-Week Pregnant Woman Managed by Conservative Surgical Treatment and Antibiotics

“…Phlegmonous gastritis was commonly reported in patients with impaired general health related to a low socioeconomic status [1], aging [1], alcoholism [1,2,18], hepatic cirrhosis [1,2,18], diabetes [1], or more specific diseases with decreased immune tolerance (e.g., T-cell leukemia [1] and HIV infection [9]). Local factors are also implicated in the genesis of phlegmonous gastritis, including acute ingestion of corrosive substances [1], alcohol intake [1,2,18], abdominal surgery [1], pyloric stenosis in children [12], duodenal or pancreatic malignancies [19], bowel ischemia [19], partial duodenal obstruction [19], long-term anti-H 2 ingestion [10], and chronic gastric or duodenal ulcer [1,18]; more recently, reports of phlegmonous gastritis have been published after invasive endoscopic procedures (repeated biliary stenting [20], mucosectomy [21]). Despite these various risk factors for phlegmonous gastritis suggesting a role for the impairment of mucosal protective factors, the pathogenesis of the disease remains largely unknown.…”

Suppurative (Phlegmonous) Gastritis Presenting as a Gastric Mass

“…An edematous submucosa is noted microscopically with an intense polymorphonuclear infiltrate and numerous Gram-positive and/or Gram-negative organisms. Suppurative gastritis has been associated with gastric malignancy [4], Helicobacter heilmannii infection in children [5], and iatrogenically with endoscopic mucosal resection [6].…”

Gastric Lymphoma Presenting as Phlegmonous Gastritis

“…Several mechanisms have been implicated such as direct invasion through an area of injury and hematogenous and lymphatic spread [4]. In some cases, there is pre-existing gastric pathology allowing entry of microorganisms like peptic ulcer, postpolypectomy, postgastric surgery, and endoscopic mucosal resection [1,5,6]. Achlorhydria as in postgastric surgery and the immunocompromised state particularly HIV infection are known predisposing factors.…”