Combined Endoscopic and Surgical Treatment of an Intramural Gastric Abscess Secondary to a Large Pancreatic Rest

Abstract

Introduction: Pancreatic rest (PR) is a well-described entity. Intramural gastric abscess has been reported in association with gastric tumors. We present a case of a large previously asymptomatic intramuscular PR becoming symptomatic secondary to abscess formation. A 39-year-old female presented with 3 days of fever, chills, and epigastric pain. Her past medical history was unremarkable. On exam her temperature was 99.1 F, BP 107/64, and pulse 111. Abdominal exam revealed epigastric tenderness. hemoglobin was 13.4, and white blood cells 25. CT scan of the abdomen with IV contrast revealed a 5-cm mass in gastric wall along the lesser curvature partially enhancing but centrally hypodense (Figure 1). An EGD revealed an 8-cm submucosal lesion with central ulceration partially obstructing the antrum, consistent with a submucosal tumor. The abscess was unroofed using the “well” biopsy technique resulting in drainage of thick white exudate. The mucosal defect was dilated to 8-mm using a CRE balloon to facilitate drainage. Aspirates revealed Strep oralis. Post-procedure the abdominal pain resolved, white blood cells returned to normal, and fever resolved. The patient completed 10 days of antibiotics. Echocardiogram was negative for endocarditis. Subsequent EUS revealed an intramural, sub-epithelial 4 x 3 cm hypoechoic mass arising from the muscularis propria (MP). Biopsies showed fragments of smooth muscle tissue with negative C-KIT and CD-34, suggestive of a leiomyoma. Due to its location deep in the MP, treatment required surgical wedge resection. Histopathological exam revealed a large PR within the MP. Pancreatic rest arises during rotation of the foregut where fragments of the pancreas separate from its main body and deposit into ectopic sites. PR is typically small and asymptomatic, found in 2-15% of autopsies, often in the antrum. Previous case reports of large intragastric PR describe bleeding, obstruction, and malignant transformation. Our case was unusual in that a large PR presented as a gastric abscess. Intramural gastric abscess has been reported with gastric tumors, foreign body ingestion, gastric surgery, and by contiguous spread. This is a novel case of a large previously asymptomatic intramuscular PR becoming symptomatic secondary to abscess formation which was drained endoscopically prior to definitive surgery.Figure 1