Intramural Gastric AbscessCase History and Review

Abstract

Intramural gastric abscess, a rare and commonly misdiagnosed condition, is a form of suppurative gastritis that was described in the time of Galen.1Gerster JCA Phlegmonous gastritis.Ann Surg. 1927; 85: 668-682Crossref PubMed Google Scholar This is a case description of intramural gastric abscess diagnosed by EUS, which is rapidly becoming the standard technique for diagnosis of this condition.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar English-language reports of cases of intramural gastric abscess published since 1972 are reviewed.Case ReportA 75-year-old man came to the emergency department with a 2-day history of intermittent dull epigastric pain that radiated to the left shoulder, fever, and chills. Sitting up did not relieve the pain. He did not have nausea or vomiting. His medical history included progressive supranuclear palsy and idiopathic dilated cardiomyopathy. The patient was in obvious distress. He was febrile (38.6°C), and there was tachycardia. There was no jaundice. Abdominal tenderness was elicited and bowel sounds were diminished, but the abdomen was soft, and no mass was palpable. Laboratory test results were within normal ranges except for the white blood cell count at 13.9 × 109/L cells (normal: 3.5−10.5 × 109/L). A flat and upright x-ray film series of the abdomen was normal, with no evidence of free air or bowel obstruction.CT identified gastric antral wall thickening with surrounding fat stranding that was strongly suggestive of gastric neoplasm. Consequently, EUS was performed for diagnosis and staging of the presumed gastric neoplasm. Endoscopic inspection during EUS revealed a 4 × 3-cm submucosal antral mass lesion with normal overlying mucosa (Fig. 1). EUS demonstrated a well-circumscribed intramural mass lesion with mixed echogenicity. The presence of internal fluid and debris raised a suspicion of an abscess. Also, there was extension of the process into the liver that suggested the formation of a liver abscess. The presence of an abscess was confirmed by EUS-guided FNA, with drainage of purulent fluid (Fig. 2). Also, a linear echogenic structure of uncertain significance was noted within the mass (Fig. 3). Follow-up CT confirmed the EUS findings and suggested that the hyperechoic linear structure (3 cm long) might represent a foreign body (Figure 4, Figure 5). The patient was given the diagnosis of an intramural gastric abscess because of penetration of the gastric wall by a foreign body, with direct hepatic extension. The foreign body was likely a fish bone.Figure 2Radial EUS image demonstrating intramural abscess in antrum of stomach.View Large Image Figure ViewerDownload (PPT)Figure 3Radial EUS image demonstrating foreign body with acoustic shadow.View Large Image Figure ViewerDownload (PPT)Figure 4CT image of bilobed antral abscess.View Large Image Figure ViewerDownload (PPT)Figure 5CT image demonstrating extension of abscess into liver parenchyma.View Large Image Figure ViewerDownload (PPT)It was thought that the complex bilobed abscess could be drained safely percutaneously; that its resolution could be followed clinically based on output from the drain; and that, with this approach, more complete drainage could be achieved. Percutaneous drainage was performed with a pigtail catheter, and 75 mL of pus were aspirated. This resulted in rapid clinical improvement. Cultures of the pus grew Candida glabrata, Streptococcus viridans, and an anaerobic nonclostridial, gram-positive bacillus. The patient was treated for 1 month with ceftriaxone, metronidazole, and fluconazole, with eventual resolution of all symptoms. CT after 6 weeks of treatment demonstrated the foreign body still to be present but there was no identifiable abscess. The patient elected not to have the foreign body removed as long as he remained asymptomatic. At 8 months' follow-up, he was asymptomatic and was not taking antibiotics.DiscussionSuppurative gastritis, a purulent inflammatory process involving the gastric wall, can occur in diffuse, localized, and mixed forms. The localized form, referred to as “intramural gastric abscess,” accounts for 5% to 15% of cases.1Gerster JCA Phlegmonous gastritis.Ann Surg. 1927; 85: 668-682Crossref PubMed Google Scholar, 3Nevin NC Eakins D Clarke SD Carson DJ Acute phlegmonous gastritis.Br J Surg. 1969; 56: 268-270Crossref PubMed Scopus (21) Google Scholar, 4Miller AI Smith B Rogers AI Phlegmonous gastritis.Gastroenterology. 1975; 68: 231-238Abstract Full Text PDF PubMed Scopus (90) Google Scholar In contrast, the more common diffuse form is characterized by diffuse gastric involvement without localized abscess formation.A review of English-language publications since 1972 identified only 17 reported cases of intramural gastric abscess.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar, 7Kang BC Kim KW Lee SW Kim JH Gastric wall abscess: imaging diagnosis and endoscopic treatment.J Comput Assist Tomogr. 1998; 22: 673-675Crossref PubMed Scopus (15) Google Scholar, 8Davies JP Billings PJ Jones MR Intramural gastric abscess mimicking leiomyoma: clinical, radiologic, and pathologic features of an unusual gastric lesion.Invest Radiol. 1993; 28: 175-176Crossref PubMed Scopus (12) Google Scholar, 9Cruz FO Soffia PS Del Rio PM Fava MP Duarte IG Acute phlegmonous gastritis with mural abscess: CT diagnosis.AJR Am J Roentgenol. 1992; 159: 767-768Crossref PubMed Scopus (20) Google Scholar, 10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 16Weiner CI Kumpe DA Diaconis JN Idiopathic gastric abscess: a bizarre intramural lesion.Am J Gastroenterol. 1975; 64: 452-459PubMed Google Scholar, 17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 18Gillespie G MacPherson GH Acute intramural abscess of the pyloric antrum: localized phlegmon.Br J Surg. 1972; 59: 197-199Crossref PubMed Scopus (6) Google Scholar Including the present case, 16 (89%) of these 18 patients presented with abdominal pain (Table 1). In most patients, the pain was epigastric, intermittent, and present for approximately 1 week before the patient sought medical attention.10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 16Weiner CI Kumpe DA Diaconis JN Idiopathic gastric abscess: a bizarre intramural lesion.Am J Gastroenterol. 1975; 64: 452-459PubMed Google Scholar, 17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar Fever was seldom noted, and no patient presented with peritonitis. Two specific, but seldom present, clinical signs are the Deininger sign (decreased pain on changing from supine to sitting position)15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar and vomiting frank pus.14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google ScholarTable 1Clinical presentation of intramuralgastric abscess in 18 patientsPatientsClinical presentationNo.%Abdominal pain1689≤7 d1056≥8 d633Presence of ulcer528Fever422 Open table in a new tab The pathogenesis of intragastric mural abscess is thought to involve a focus of injury to the gastric mucosa because of penetrating trauma from an ingested foreign body or an endoscopic biopsy.1Gerster JCA Phlegmonous gastritis.Ann Surg. 1927; 85: 668-682Crossref PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar As in our patient, others have noted development of an intramural gastric abscess together with a liver abscess after perforation of the gastric wall by ingested bones.17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 19Tsai JL Than MM Wu CJ Sue D Keh CT Wang CC Liver abscess secondary to fish bone penetration of the gastric wall: a case report.Zhonghua Yi Xue Za Zhi (Taipei). 1999; 62: 51-54PubMed Google Scholar, 20Frank P Behnke KH Behrmann E Stomach lining abscess following perforation by poultry bones: a rare and unusual differential diagnosis from stomach carcinoma [German].ROFO Fortschr Geb Rontgenstr Nuklearmed. 1980; 133: 325-326Crossref PubMed Google Scholar Neither peptic ulcer disease nor malignancy appears to predispose to suppurative gastritis. Coexisting gastric ulcers were present in 5 reported cases.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar However, it is unclear whether peptic ulcer predisposes to suppurative gastritis or develops secondarily.The most commonly reported pathogen is Streptococcus, which is implicated in up to 75% of cases.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar Other less commonly reported organisms include Escherichia, Staphylococcus, Clostridium, Bacillus, and Proteus.17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar As in the present case, polymicrobial infection may occur.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 9Cruz FO Soffia PS Del Rio PM Fava MP Duarte IG Acute phlegmonous gastritis with mural abscess: CT diagnosis.AJR Am J Roentgenol. 1992; 159: 767-768Crossref PubMed Scopus (20) Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar Our patient had an infection with Streptococcus viridans, an anaerobic nonclostridial gram-positive bacillus and Candida glabrata. To our knowledge, this is the first reported case of an intramural gastric abscess, in part, because of a fungal organism.Treatment modalities and survival for the 18 reported patients with intramural gastric abscess are shown in Table 2. Until recently, the recommended therapy for intramural gastric abscess was gastrectomy in combination with antibiotics. However, technical advances now allow either radiologic and endoscopic intervention. Endoscopic drainage with or without antibiotics has been shown to be effective.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 7Kang BC Kim KW Lee SW Kim JH Gastric wall abscess: imaging diagnosis and endoscopic treatment.J Comput Assist Tomogr. 1998; 22: 673-675Crossref PubMed Scopus (15) Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar Percutaneous drainage also is reported to be successful.6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar Percutaneous drainage, in combination with antibiotics, was effective treatment in the present case despite direct extension of the abscess into the liver. However, the foreign body was not removed and may serve as a nidus for recurrence of the abscess. Endoscopic retrieval was recommended, but the patient declined because all symptoms had resolved. Although one report described successful treatment of a patient with diffuse suppurative gastritis with antibiotics alone, this approach should be regarded with caution.21Hu DC McGrath KM Jowell PS Killenberg PG Phlegmonous gastritis: successful treatment with antibiotics and resolution documented by EUS.Gastrointest Endosc. 2000; 52: 793-795Abstract Full Text Full Text PDF PubMed Scopus (33) Google ScholarTable 2Treatment and survival for 18 patients with intramural gastric abscessPatientsTreatedSurvivalTreatmentNo.%No.%Surgery116111100Endoscopic drainage ± antibiotics4224100Percutaneous drainage ± antibiotics2112100Antibiotics alone1600 Open table in a new tab The present case highlights many of the salient points in the presentation, evaluation, and management of intramural gastric abscess. The initial presentation and CT findings raised a suspicion of gastric neoplasm. EUS was invaluable in establishing the diagnosis and determining the extent of disease. Although percutaneous drainage was performed, drainage also may be performed by EUS. Despite hepatic extension of the abscess and retention of the foreign body, the patient had a complete response to therapy. Whether the remaining foreign body will serve as a nidus for abscess recurrence is unknown. To our knowledge, the present case is the first in which a fungal organism, Candida glabrata, was isolated from an intramural abscess. Intramural gastric abscess, a rare and commonly misdiagnosed condition, is a form of suppurative gastritis that was described in the time of Galen.1Gerster JCA Phlegmonous gastritis.Ann Surg. 1927; 85: 668-682Crossref PubMed Google Scholar This is a case description of intramural gastric abscess diagnosed by EUS, which is rapidly becoming the standard technique for diagnosis of this condition.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar English-language reports of cases of intramural gastric abscess published since 1972 are reviewed. Case ReportA 75-year-old man came to the emergency department with a 2-day history of intermittent dull epigastric pain that radiated to the left shoulder, fever, and chills. Sitting up did not relieve the pain. He did not have nausea or vomiting. His medical history included progressive supranuclear palsy and idiopathic dilated cardiomyopathy. The patient was in obvious distress. He was febrile (38.6°C), and there was tachycardia. There was no jaundice. Abdominal tenderness was elicited and bowel sounds were diminished, but the abdomen was soft, and no mass was palpable. Laboratory test results were within normal ranges except for the white blood cell count at 13.9 × 109/L cells (normal: 3.5−10.5 × 109/L). A flat and upright x-ray film series of the abdomen was normal, with no evidence of free air or bowel obstruction.CT identified gastric antral wall thickening with surrounding fat stranding that was strongly suggestive of gastric neoplasm. Consequently, EUS was performed for diagnosis and staging of the presumed gastric neoplasm. Endoscopic inspection during EUS revealed a 4 × 3-cm submucosal antral mass lesion with normal overlying mucosa (Fig. 1). EUS demonstrated a well-circumscribed intramural mass lesion with mixed echogenicity. The presence of internal fluid and debris raised a suspicion of an abscess. Also, there was extension of the process into the liver that suggested the formation of a liver abscess. The presence of an abscess was confirmed by EUS-guided FNA, with drainage of purulent fluid (Fig. 2). Also, a linear echogenic structure of uncertain significance was noted within the mass (Fig. 3). Follow-up CT confirmed the EUS findings and suggested that the hyperechoic linear structure (3 cm long) might represent a foreign body (Figure 4, Figure 5). The patient was given the diagnosis of an intramural gastric abscess because of penetration of the gastric wall by a foreign body, with direct hepatic extension. The foreign body was likely a fish bone.Figure 3Radial EUS image demonstrating foreign body with acoustic shadow.View Large Image Figure ViewerDownload (PPT)Figure 4CT image of bilobed antral abscess.View Large Image Figure ViewerDownload (PPT)Figure 5CT image demonstrating extension of abscess into liver parenchyma.View Large Image Figure ViewerDownload (PPT)It was thought that the complex bilobed abscess could be drained safely percutaneously; that its resolution could be followed clinically based on output from the drain; and that, with this approach, more complete drainage could be achieved. Percutaneous drainage was performed with a pigtail catheter, and 75 mL of pus were aspirated. This resulted in rapid clinical improvement. Cultures of the pus grew Candida glabrata, Streptococcus viridans, and an anaerobic nonclostridial, gram-positive bacillus. The patient was treated for 1 month with ceftriaxone, metronidazole, and fluconazole, with eventual resolution of all symptoms. CT after 6 weeks of treatment demonstrated the foreign body still to be present but there was no identifiable abscess. The patient elected not to have the foreign body removed as long as he remained asymptomatic. At 8 months' follow-up, he was asymptomatic and was not taking antibiotics. A 75-year-old man came to the emergency department with a 2-day history of intermittent dull epigastric pain that radiated to the left shoulder, fever, and chills. Sitting up did not relieve the pain. He did not have nausea or vomiting. His medical history included progressive supranuclear palsy and idiopathic dilated cardiomyopathy. The patient was in obvious distress. He was febrile (38.6°C), and there was tachycardia. There was no jaundice. Abdominal tenderness was elicited and bowel sounds were diminished, but the abdomen was soft, and no mass was palpable. Laboratory test results were within normal ranges except for the white blood cell count at 13.9 × 109/L cells (normal: 3.5−10.5 × 109/L). A flat and upright x-ray film series of the abdomen was normal, with no evidence of free air or bowel obstruction. CT identified gastric antral wall thickening with surrounding fat stranding that was strongly suggestive of gastric neoplasm. Consequently, EUS was performed for diagnosis and staging of the presumed gastric neoplasm. Endoscopic inspection during EUS revealed a 4 × 3-cm submucosal antral mass lesion with normal overlying mucosa (Fig. 1). EUS demonstrated a well-circumscribed intramural mass lesion with mixed echogenicity. The presence of internal fluid and debris raised a suspicion of an abscess. Also, there was extension of the process into the liver that suggested the formation of a liver abscess. The presence of an abscess was confirmed by EUS-guided FNA, with drainage of purulent fluid (Fig. 2). Also, a linear echogenic structure of uncertain significance was noted within the mass (Fig. 3). Follow-up CT confirmed the EUS findings and suggested that the hyperechoic linear structure (3 cm long) might represent a foreign body (Figure 4, Figure 5). The patient was given the diagnosis of an intramural gastric abscess because of penetration of the gastric wall by a foreign body, with direct hepatic extension. The foreign body was likely a fish bone. It was thought that the complex bilobed abscess could be drained safely percutaneously; that its resolution could be followed clinically based on output from the drain; and that, with this approach, more complete drainage could be achieved. Percutaneous drainage was performed with a pigtail catheter, and 75 mL of pus were aspirated. This resulted in rapid clinical improvement. Cultures of the pus grew Candida glabrata, Streptococcus viridans, and an anaerobic nonclostridial, gram-positive bacillus. The patient was treated for 1 month with ceftriaxone, metronidazole, and fluconazole, with eventual resolution of all symptoms. CT after 6 weeks of treatment demonstrated the foreign body still to be present but there was no identifiable abscess. The patient elected not to have the foreign body removed as long as he remained asymptomatic. At 8 months' follow-up, he was asymptomatic and was not taking antibiotics. DiscussionSuppurative gastritis, a purulent inflammatory process involving the gastric wall, can occur in diffuse, localized, and mixed forms. The localized form, referred to as “intramural gastric abscess,” accounts for 5% to 15% of cases.1Gerster JCA Phlegmonous gastritis.Ann Surg. 1927; 85: 668-682Crossref PubMed Google Scholar, 3Nevin NC Eakins D Clarke SD Carson DJ Acute phlegmonous gastritis.Br J Surg. 1969; 56: 268-270Crossref PubMed Scopus (21) Google Scholar, 4Miller AI Smith B Rogers AI Phlegmonous gastritis.Gastroenterology. 1975; 68: 231-238Abstract Full Text PDF PubMed Scopus (90) Google Scholar In contrast, the more common diffuse form is characterized by diffuse gastric involvement without localized abscess formation.A review of English-language publications since 1972 identified only 17 reported cases of intramural gastric abscess.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar, 7Kang BC Kim KW Lee SW Kim JH Gastric wall abscess: imaging diagnosis and endoscopic treatment.J Comput Assist Tomogr. 1998; 22: 673-675Crossref PubMed Scopus (15) Google Scholar, 8Davies JP Billings PJ Jones MR Intramural gastric abscess mimicking leiomyoma: clinical, radiologic, and pathologic features of an unusual gastric lesion.Invest Radiol. 1993; 28: 175-176Crossref PubMed Scopus (12) Google Scholar, 9Cruz FO Soffia PS Del Rio PM Fava MP Duarte IG Acute phlegmonous gastritis with mural abscess: CT diagnosis.AJR Am J Roentgenol. 1992; 159: 767-768Crossref PubMed Scopus (20) Google Scholar, 10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 16Weiner CI Kumpe DA Diaconis JN Idiopathic gastric abscess: a bizarre intramural lesion.Am J Gastroenterol. 1975; 64: 452-459PubMed Google Scholar, 17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 18Gillespie G MacPherson GH Acute intramural abscess of the pyloric antrum: localized phlegmon.Br J Surg. 1972; 59: 197-199Crossref PubMed Scopus (6) Google Scholar Including the present case, 16 (89%) of these 18 patients presented with abdominal pain (Table 1). In most patients, the pain was epigastric, intermittent, and present for approximately 1 week before the patient sought medical attention.10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 16Weiner CI Kumpe DA Diaconis JN Idiopathic gastric abscess: a bizarre intramural lesion.Am J Gastroenterol. 1975; 64: 452-459PubMed Google Scholar, 17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar Fever was seldom noted, and no patient presented with peritonitis. Two specific, but seldom present, clinical signs are the Deininger sign (decreased pain on changing from supine to sitting position)15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar and vomiting frank pus.14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google ScholarTable 1Clinical presentation of intramuralgastric abscess in 18 patientsPatientsClinical presentationNo.%Abdominal pain1689≤7 d1056≥8 d633Presence of ulcer528Fever422 Open table in a new tab The pathogenesis of intragastric mural abscess is thought to involve a focus of injury to the gastric mucosa because of penetrating trauma from an ingested foreign body or an endoscopic biopsy.1Gerster JCA Phlegmonous gastritis.Ann Surg. 1927; 85: 668-682Crossref PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar As in our patient, others have noted development of an intramural gastric abscess together with a liver abscess after perforation of the gastric wall by ingested bones.17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 19Tsai JL Than MM Wu CJ Sue D Keh CT Wang CC Liver abscess secondary to fish bone penetration of the gastric wall: a case report.Zhonghua Yi Xue Za Zhi (Taipei). 1999; 62: 51-54PubMed Google Scholar, 20Frank P Behnke KH Behrmann E Stomach lining abscess following perforation by poultry bones: a rare and unusual differential diagnosis from stomach carcinoma [German].ROFO Fortschr Geb Rontgenstr Nuklearmed. 1980; 133: 325-326Crossref PubMed Google Scholar Neither peptic ulcer disease nor malignancy appears to predispose to suppurative gastritis. Coexisting gastric ulcers were present in 5 reported cases.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar However, it is unclear whether peptic ulcer predisposes to suppurative gastritis or develops secondarily.The most commonly reported pathogen is Streptococcus, which is implicated in up to 75% of cases.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar Other less commonly reported organisms include Escherichia, Staphylococcus, Clostridium, Bacillus, and Proteus.17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar As in the present case, polymicrobial infection may occur.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 9Cruz FO Soffia PS Del Rio PM Fava MP Duarte IG Acute phlegmonous gastritis with mural abscess: CT diagnosis.AJR Am J Roentgenol. 1992; 159: 767-768Crossref PubMed Scopus (20) Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar Our patient had an infection with Streptococcus viridans, an anaerobic nonclostridial gram-positive bacillus and Candida glabrata. To our knowledge, this is the first reported case of an intramural gastric abscess, in part, because of a fungal organism.Treatment modalities and survival for the 18 reported patients with intramural gastric abscess are shown in Table 2. Until recently, the recommended therapy for intramural gastric abscess was gastrectomy in combination with antibiotics. However, technical advances now allow either radiologic and endoscopic intervention. Endoscopic drainage with or without antibiotics has been shown to be effective.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 7Kang BC Kim KW Lee SW Kim JH Gastric wall abscess: imaging diagnosis and endoscopic treatment.J Comput Assist Tomogr. 1998; 22: 673-675Crossref PubMed Scopus (15) Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar Percutaneous drainage also is reported to be successful.6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar Percutaneous drainage, in combination with antibiotics, was effective treatment in the present case despite direct extension of the abscess into the liver. However, the foreign body was not removed and may serve as a nidus for recurrence of the abscess. Endoscopic retrieval was recommended, but the patient declined because all symptoms had resolved. Although one report described successful treatment of a patient with diffuse suppurative gastritis with antibiotics alone, this approach should be regarded with caution.21Hu DC McGrath KM Jowell PS Killenberg PG Phlegmonous gastritis: successful treatment with antibiotics and resolution documented by EUS.Gastrointest Endosc. 2000; 52: 793-795Abstract Full Text Full Text PDF PubMed Scopus (33) Google ScholarTable 2Treatment and survival for 18 patients with intramural gastric abscessPatientsTreatedSurvivalTreatmentNo.%No.%Surgery116111100Endoscopic drainage ± antibiotics4224100Percutaneous drainage ± antibiotics2112100Antibiotics alone1600 Open table in a new tab The present case highlights many of the salient points in the presentation, evaluation, and management of intramural gastric abscess. The initial presentation and CT findings raised a suspicion of gastric neoplasm. EUS was invaluable in establishing the diagnosis and determining the extent of disease. Although percutaneous drainage was performed, drainage also may be performed by EUS. Despite hepatic extension of the abscess and retention of the foreign body, the patient had a complete response to therapy. Whether the remaining foreign body will serve as a nidus for abscess recurrence is unknown. To our knowledge, the present case is the first in which a fungal organism, Candida glabrata, was isolated from an intramural abscess. Suppurative gastritis, a purulent inflammatory process involving the gastric wall, can occur in diffuse, localized, and mixed forms. The localized form, referred to as “intramural gastric abscess,” accounts for 5% to 15% of cases.1Gerster JCA Phlegmonous gastritis.Ann Surg. 1927; 85: 668-682Crossref PubMed Google Scholar, 3Nevin NC Eakins D Clarke SD Carson DJ Acute phlegmonous gastritis.Br J Surg. 1969; 56: 268-270Crossref PubMed Scopus (21) Google Scholar, 4Miller AI Smith B Rogers AI Phlegmonous gastritis.Gastroenterology. 1975; 68: 231-238Abstract Full Text PDF PubMed Scopus (90) Google Scholar In contrast, the more common diffuse form is characterized by diffuse gastric involvement without localized abscess formation. A review of English-language publications since 1972 identified only 17 reported cases of intramural gastric abscess.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar, 7Kang BC Kim KW Lee SW Kim JH Gastric wall abscess: imaging diagnosis and endoscopic treatment.J Comput Assist Tomogr. 1998; 22: 673-675Crossref PubMed Scopus (15) Google Scholar, 8Davies JP Billings PJ Jones MR Intramural gastric abscess mimicking leiomyoma: clinical, radiologic, and pathologic features of an unusual gastric lesion.Invest Radiol. 1993; 28: 175-176Crossref PubMed Scopus (12) Google Scholar, 9Cruz FO Soffia PS Del Rio PM Fava MP Duarte IG Acute phlegmonous gastritis with mural abscess: CT diagnosis.AJR Am J Roentgenol. 1992; 159: 767-768Crossref PubMed Scopus (20) Google Scholar, 10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 16Weiner CI Kumpe DA Diaconis JN Idiopathic gastric abscess: a bizarre intramural lesion.Am J Gastroenterol. 1975; 64: 452-459PubMed Google Scholar, 17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 18Gillespie G MacPherson GH Acute intramural abscess of the pyloric antrum: localized phlegmon.Br J Surg. 1972; 59: 197-199Crossref PubMed Scopus (6) Google Scholar Including the present case, 16 (89%) of these 18 patients presented with abdominal pain (Table 1). In most patients, the pain was epigastric, intermittent, and present for approximately 1 week before the patient sought medical attention.10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 16Weiner CI Kumpe DA Diaconis JN Idiopathic gastric abscess: a bizarre intramural lesion.Am J Gastroenterol. 1975; 64: 452-459PubMed Google Scholar, 17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar Fever was seldom noted, and no patient presented with peritonitis. Two specific, but seldom present, clinical signs are the Deininger sign (decreased pain on changing from supine to sitting position)15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar and vomiting frank pus.14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar The pathogenesis of intragastric mural abscess is thought to involve a focus of injury to the gastric mucosa because of penetrating trauma from an ingested foreign body or an endoscopic biopsy.1Gerster JCA Phlegmonous gastritis.Ann Surg. 1927; 85: 668-682Crossref PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar As in our patient, others have noted development of an intramural gastric abscess together with a liver abscess after perforation of the gastric wall by ingested bones.17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 19Tsai JL Than MM Wu CJ Sue D Keh CT Wang CC Liver abscess secondary to fish bone penetration of the gastric wall: a case report.Zhonghua Yi Xue Za Zhi (Taipei). 1999; 62: 51-54PubMed Google Scholar, 20Frank P Behnke KH Behrmann E Stomach lining abscess following perforation by poultry bones: a rare and unusual differential diagnosis from stomach carcinoma [German].ROFO Fortschr Geb Rontgenstr Nuklearmed. 1980; 133: 325-326Crossref PubMed Google Scholar Neither peptic ulcer disease nor malignancy appears to predispose to suppurative gastritis. Coexisting gastric ulcers were present in 5 reported cases.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 10Briggs TP Tyler XE Dowling BL Gastric abscess: an unusual presentation.Case report. Eur J Surg. 1991; 157: 365-366Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar However, it is unclear whether peptic ulcer predisposes to suppurative gastritis or develops secondarily. The most commonly reported pathogen is Streptococcus, which is implicated in up to 75% of cases.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar, 13Cowan SS Sablin JG Mori K Phlegmonous gastritis: report of a case.Mt Sinai J Med. 1983; 50: 417-419PubMed Google Scholar, 14Lifton LJ Schlossberg D Phlegmonous gastritis after endoscopic polypectomy.Ann Intern Med. 1982; 97: 373-375Crossref PubMed Scopus (33) Google Scholar, 15Murphy JF Graham DY Frankel NB Spjut HJ Intramural gastric abscess.Am J Surg. 1976; 131: 618-621Abstract Full Text PDF PubMed Scopus (22) Google Scholar Other less commonly reported organisms include Escherichia, Staphylococcus, Clostridium, Bacillus, and Proteus.17Smith GE Subacute phlegmonous gastritis simulating intramural neoplasm: case report and review.Gastrointest Endosc. 1972; 19: 23-26Abstract Full Text PDF PubMed Scopus (12) Google Scholar As in the present case, polymicrobial infection may occur.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 9Cruz FO Soffia PS Del Rio PM Fava MP Duarte IG Acute phlegmonous gastritis with mural abscess: CT diagnosis.AJR Am J Roentgenol. 1992; 159: 767-768Crossref PubMed Scopus (20) Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar Our patient had an infection with Streptococcus viridans, an anaerobic nonclostridial gram-positive bacillus and Candida glabrata. To our knowledge, this is the first reported case of an intramural gastric abscess, in part, because of a fungal organism. Treatment modalities and survival for the 18 reported patients with intramural gastric abscess are shown in Table 2. Until recently, the recommended therapy for intramural gastric abscess was gastrectomy in combination with antibiotics. However, technical advances now allow either radiologic and endoscopic intervention. Endoscopic drainage with or without antibiotics has been shown to be effective.2Will U Masri R Bosseckert H Knopke A Schonlebe J Justus J Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment.Endoscopy. 1998; 30: 432-435Crossref PubMed Scopus (25) Google Scholar, 5Kiil C Rosenberg J Gastric intramural abscess successfully drained during gastroscopy.Gastrointest Endosc. 2001; 53: 231-232Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 7Kang BC Kim KW Lee SW Kim JH Gastric wall abscess: imaging diagnosis and endoscopic treatment.J Comput Assist Tomogr. 1998; 22: 673-675Crossref PubMed Scopus (15) Google Scholar, 11Lantz PE Westerman EL Seifert RW Gastric wall abscess drained at endoscopy.Gastrointest Endosc. 1989; 35: 272-274Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 12Aviles JF Fernandez-Seara J Barcena R Domiinguez F Fernandez C Ledo L Localized phlegmonous gastritis: endoscopic view.Endoscopy. 1988; 20: 38-39Crossref PubMed Scopus (28) Google Scholar Percutaneous drainage also is reported to be successful.6Iwakiri Y Kabemura T Yasuda D Okabe H Soejima A Miyagahara T et al.A case of acute phlegmonous gastritis successfully treated with antibiotics.J Clin Gastroenterol. 1999; 28: 175-177Crossref PubMed Scopus (45) Google Scholar Percutaneous drainage, in combination with antibiotics, was effective treatment in the present case despite direct extension of the abscess into the liver. However, the foreign body was not removed and may serve as a nidus for recurrence of the abscess. Endoscopic retrieval was recommended, but the patient declined because all symptoms had resolved. Although one report described successful treatment of a patient with diffuse suppurative gastritis with antibiotics alone, this approach should be regarded with caution.21Hu DC McGrath KM Jowell PS Killenberg PG Phlegmonous gastritis: successful treatment with antibiotics and resolution documented by EUS.Gastrointest Endosc. 2000; 52: 793-795Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The present case highlights many of the salient points in the presentation, evaluation, and management of intramural gastric abscess. The initial presentation and CT findings raised a suspicion of gastric neoplasm. EUS was invaluable in establishing the diagnosis and determining the extent of disease. Although percutaneous drainage was performed, drainage also may be performed by EUS. Despite hepatic extension of the abscess and retention of the foreign body, the patient had a complete response to therapy. Whether the remaining foreign body will serve as a nidus for abscess recurrence is unknown. To our knowledge, the present case is the first in which a fungal organism, Candida glabrata, was isolated from an intramural abscess.