2745 Intramural Gastric Abscess: A Rare Condition Diagnosed and Managed With Endoscopic Ultrasound

Abstract

INTRODUCTION: Intramural gastric abscess are rare presentations of suppurative gastritis which are often challenging to diagnose and manage. The pathology of gastric abscess formation is not completely understood but theorized cause include hematogenous spread or direct gastric inoculation from trauma. Predisposing factors include diabetes, foreign objects, or gastric surgery. The most common organisms identified are Streptococci. Historically, the diagnosis and management included surgical intervention however advancements in the field of endoscopic ultrasound provide a minimally invasive, accurate, and economical alternative. CASE DESCRIPTION/METHODS: A 75-year old female with a past medical history diabetes mellitus presents to the emergency department with epigastric pain. The patient’s symptoms started two days prior with progressive sharp epigastric abdominal pain with nausea and non-bloody non-bilious vomiting. Vitals revealed a temperature 100 °F, blood pressure 148/87 mmHg, heart rate 104 beats/min, and respiratory rate of 18 breaths/min, examination revealed a soft abdomen with epigastric tenderness with deep palpation. Initial lab work was only significant for a leukocytosis of 11,300 cells/mm3 with a left shift. She underwent computed tomography (CT) of her abdomen which revealed hypoenhancement possible abscess in the anterior wall measuring 2.5 cm in diameter. (Figure 1). EGD revealed a deformity consistent with extrinsic compression vs intramural lesion found in the gastric antrum. Upper endoscopic ultrasound (UEUS) revealed a 45 mm × 40 mm intramural (subepithelial) heterogenous density containing mass versus debris, FNA drainage produced 5mL of opaque, light brown/purulent thick fluid (Figure 3). Cultures Streptococcus intermedius and Micrococcus species. Pathology was negative. Patient symptoms improved the following day and she completed a 3 week course of oral levofloxacin and metronidazole. Four week follow up CT scan showed complete resolution of the abscess. DISCUSSION: This case outlines a rare condition of intramural gastric abscess managed successfully with UEUS. The patient had an unusual abrupt onset of symptoms and Streptococci intermedius cultures which has not been previously reported from our literature search. Surgical intervention has been the mainstay of treatment historically however endoscopic ultrasound imaging provides a favorable alternative which is safe, minimally invasive, and cost effective approach.