S2285 A Rare Cause of Upper Gastrointestinal Bleeding: Sarcina ventriculi

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Introduction: Sarcina ventriculi is a gram-positive anaerobic coccus that thrives in acidic environments and uses carbohydrate fermentation as its sole source of energy. The organism was first observed in gastric contents in 1842 after a patient presented with months of bloating, nausea, and emesis. Additional investigation revealed that the bacteria was most commonly identified in patients with delayed gastric emptying or gastric outlet obstruction. Sarcina ventriculi has been implicated in cases of gastric ulcer, emphysematous gastritis, and peritonitis following gastric perforation as well as gastric adenocarcinoma and pancreatic adenocarcinoma. Case Description/Methods: A 68-year-old woman with a history of acid reflux, type 2 diabetes, hypertension and cardiomyopathy presented with hematemesis for one day. She was hemodynamically resuscitated and given an intravenous proton pump inhibitor. Esophagogastroduodenoscopy (EGD) demonstrated a large area of deeply erythematous mucosa with well-defined margins involving a large amount of the gastric fundus and proximal body. Within this area was a 2-3 cm irregular non-bleeding necrotic ulcer in the gastric body suggestive of malignancy (Figure 1A). Multiple biopsies were taken from the ulcer edge and erythematous mucosa. Pathology was significant for erosive gastropathy with superficial erosion and reactive changes as well as ulcer pathology with mucosal necrosis and erosion. Interestingly, there were scattered intraluminal microorganisms characteristic of Sarcina ventriculi (Figure 1B). Based on the few available case reports, the patient was treated with one week of metronidazole, ciprofloxacin, sucralfate, and pantoprazole. The patient is scheduled for repeat EGD to follow up in one month. Discussion: A review of the literature revealed that the initial presenting symptom of Sarcina ventriculi as hematemesis is exceedingly rare. Endoscopic evaluation in this case revealed a unique well-defined margin between normal and abnormal mucosa that, to our knowledge, is not previously characterized. There is no consensus regarding the best therapeutic agents or treatment duration. Further evaluation and documentation of resolution or persistence of Sarcina ventriculi in this case is pending completion of antibiotics and repeat EGD. These results may contribute to establishing an appropriate treatment regimen for future cases. The organism’s association with serious pathology make its identification and treatment clinically significant.Figure 1.: A) A 2-3 cm irregular non-bleeding necrotic ulcer in the gastric body and B) Necroinflammatory debris (black arrows) and admixed Sarcina ventriculi organisms arranged in tetrads (yellow arrows), 1000x H&E.