An unexpected finding during gastroscopy

Abstract

At the age of 3 years, the patient had undergone surgery for repair of an atrial septal defect and had an epicardial pacing system placed for congenital atrioventricular block. This was replaced with an endocardial dual chamber pacemaker at the age of 15 years. The epicardial pulse generator and leads were left in situ. Now aged 23 years old, the patient presented with a 48-hour history of right shoulder tip pain, palpitations, rigors and subsequent melaena. On examination she was pyrexic (40°C) with vague upper abdominal tenderness. She had no overt features of bacterial endocarditis. Her chest X-ray shows both the endocardial and epicardial pacing system in situ (Figure 1). Preliminary haematological investigations revealed a microcytic hypochromic anaemia (7.4 g/dl), neutrophilia (25x109/ml), an erythrocyte sedimentation rate of 121 mm/hr and a C-reactive protein of 272 mg/litre. Repeated blood cultures were negative. Transoesophageal echocardiography showed no evidence of valvular or pacemaker lead vegetations. Gastroscopy revealed the redundant epicardial pacemaker generator inside the stomach with evidence of gastric ulceration (Figure 2). After initial resuscitation with blood products and parenteral antibiotics she underwent surgery where through a gastrostomy the pulse generator was retrieved. At laparotomy the left lobe of the liver appeared unhealthy and subsequent computed tomography scan of the abdomen confirmed the presence of multiple intrahepatic abscesses (Figure 3). It was decided that the hepatic abscess were not suitable for percutaneous drainage as they were multiple and predominantly in the left lobe of the liver. She continued on a protracted course of intravenous antibiotics and made a full recovery thereafter.