2735 Phlegmonous Gastritis

Abstract

INTRODUCTION: Phlegmonous gastritis (PG) is a rare cause of abdominal infection with a mortality rate up to 42%. PG presents a diagnostic and therapeutic challenge given the low incidence and non-standardized treatment options. We present a case of PG successfully treated with early antibiotic therapy. CASE DESCRIPTION/METHODS: A 47-year-old man with uncontrolled type 2 diabetes mellitus presented with four days of subjective fevers, abdominal pain, and vomiting. The patient was tachycardic (122 beats/min) and had epigastric tenderness without guarding or rebound. Initial studies revealed leukocytosis (30,000/mm³) and Gram-positive bacteremia, later identified as ß-hemolytic group A Streptococcus. The stomach was diffusely thickened to 16 mm on contrast-enhanced computed abdominal tomography (Figure 1). Endoscopy revealed diffuse gastric thickening with erythema and a nonbleeding 6 mm ulcer on the lesser curvature of the gastric body. Deep biopsy of the ulcer by cold forceps produced a purulent drainage (Figure 2). Subsequent endoscopic ultrasonography (EUS) found a 12 mm thickened gastric wall involving the deep mucosa, thus further biopsy was obtained. The biopsies from both endoscopy and EUS showed acute neutrophilic inflammation with micro-abscesses; Helicobacter pylori was not identified. The patient received three days of piperacillin/tazobactam followed by seven days of ampicillin/sulbactam, with resolution of symptoms. DISCUSSION: PG is a rapidly progressive and frequently fatal bacterial infection of the gastric wall. The etiology of PG remains unclear, but can be caused by local or hematogenous spread of infection. Streptococcusspp. accounts for 70% of cases, and up to one-third of infections are polymicrobial. Risk factors include gastric mucosal injury, diabetes mellitus, and alcoholism. Diagnosis is commonly delayed as clinical manifestations are nonspecific. High clinical suspicion and early radiographic testing are important to identify gastric wall thickening, which is supportive of the diagnosis. PG primarily affects the gastric submucosa but may extend to deeper layers. Histopathology is of limited benefit, as standard forceps biopsy collects insufficient submucosal tissue. Optimal treatment is not known. When diagnosis is delayed, surgical intervention is often required. Medical therapy alone has been associated with increased mortality rates; however, in cases of early diagnosis and empiric antibiotic treatment, medical therapy alone may be sufficient.