An Unusual Case of Recurrent Gastric Abscess

Suppurative gastritis (SG) is an uncommon, often fatal condition characterized by suppurative bacterial infection of the stomach arising from a local or disseminated hematogenous infection. SG is divided into two categories based upon the extension of pathology: the more common phlegmonous diffuse gastritis and the much rarer intramural localized gastric abscess. In this case report, we describe a case of recurrent gastric abscess in a 28-year-old woman.

Case Report

A 28-year-old woman presented with severe epigastric left-upper-quadrant pain that was progressive and burning in nature without radiating for 6 days. Her associated symptoms included weakness, nausea, and vomiting of all solids and liquids over the previous 2 days. The patient denied any changes in bowel habits, blood in stool, hematemesis, fever, or chills, and her past medical history was significant for depression, irritable bowel syndrome, and cholecystectomy. Her first episode of pain was 9 months earlier when she developed similar severe epigastric pain with nausea and vomiting, for which she was admitted to hospital. Upper endoscopy at that time revealed the presence of antral thickening, and biopsies were negative for malignancy but positive for Helicobacter pylori infection. Computed tomography (CT) scan at that time showed stranding around the antral region. The patient was treated with antibiotics, and follow-up CT scan demonstrated resolution of perinatal stranding. Eight months later, she presented with similar symptoms and findings on upper endoscopy and CT scan of the abdomen and was once again treated with intravenous (IV) antibiotics until resolution of her symptoms and hospital discharge. The patient presented again to the hospital 1 month later (the current presentation) with left-upper-quadrant pain for 6 days and was referred for endoscopic ultrasound (EUS). Her social history was significant for cigarette smoking (<1 pack per week) and occasional alcohol use. Physical examination revealed dry mucous membranes, mild orthostasis that resolved with IV fluids, a soft abdomen with positive bowel sounds, and tenderness to palpation in the left upper quadrant. Rectal examination was guaiac-negative, and a complete blood count was significant for leukocytosis with left shift. CT scan of the abdomen demonstrated 3-cm soft tissue, fluid-filled density in the prepyloric antrum consistent with an abscess or a malignancy with central necrosis or hemorrhage (Figure 1). Upper endoscopy showed a 3-cm submucosal antral mass in the prepyloric area (Figure 2), and EUS demonstrated a 2-cm hypoechoic submucosal lesion suggestive of an abscess in the antrum that was confined to subcutaneous/muscularis propria (Figure 3). The lesion was opened with a cystotome, and following drainage of pus, a 10 Fr × 5-cm straight plastic stent was inserted into the cyst. The patient's pain rapidly resolved after drainage, and she was immediately started on IV piperacillin/tazobactam (Zosyn, Wyeth). Aspirate cultures were positive for Streptococcus species, and follow-up EUS showed a possible 2-cm foreign body, which may have been the cause of her recurrent abscess. She was discharged home on oral antibiotics and the recommendation to follow-up with surgical treatment. The patient had a recurrent abscess 2 months later and underwent distal gastrectomy with Rouxen-Y gastrojejunostomy. She recovered postoperatively and was discharged in stable condition and has been doing well since then.

Figure 1.

Computed tomography scans of the abdomen demonstrating a gastric intraluminal wall abscess (indicated by the arrows), shown from different cut images.

Figure 2.

Submucosal antral mass measuring 3 cm in the prepyloric area, shown from different angles during endoscopy.

Figure 3.

Endoscopic ultrasound image demonstrating a 2-cm hypoechoic submucosal lesion suggestive of an abscess in the antrum that is confined to subcutaneous/muscularis propria.

Discussion

Gastric abscess was first described in the time of Galen (AD 150) as an erysipelas tumor of the stomach,¹ whereas the first description of SG was recorded by Cruveilhier in 1862² and a case series of 215 SG cases was later reported in 1919 by Sundberg.³ Two types of SG have been described in the literature: a diffuse or phlegmonous variant type of SG as opposed to a localized or intramural gastric abscess. A review of English language publications since 1972 identified only 18 reported cases of intramural gastric abscess.⁴

Normally, the stomach harbors low numbers of bacteria due to its highly acidic contents. Because of this semisterile environment, gastric wall abscesses are very rare.⁵ When the protective effect of gastric acid is absent, bacterial overgrowth can occur. This phenomenon has been reported in the elderly and patients with achlorhydria, gastric ulcer, or gastric carcinoma.⁶ The pathogenesis of intragastric mural abscess is thought to involve a focus of injury to the gastric mucosa due to penetrating trauma from an ingested foreign body or an endoscopic biopsy.^1,7 There have been reports of contiguous extension of infection into the gastric wall secondary to pancreatitis, cholecystitis, appendicitis, and diverticulitis. In addition, infection may arise from foreign body ingestion (fish bones), inflammation of ectopic pancreatic tissue, endoscopic biopsies, and gastric surgery. There have been reports of superinfection of gastric wall neoplasms, including carcinomas and leiomyosarcomas.^2,8,9 Patient-related risk factors for the development of SG include alcoholism, older age, diabetes mellitus, hypochlorhydria, achlorhydria, and immunosuppression. The most commonly reported pathogen is Streptococcus, which is implicated in up to 75% of cases.^7,10–13 Other less commonly reported organisms include Escherichia, Staphylococcus, Clostridium, Bacillus, and Proteus.¹⁴ In most cases, epigastric abdominal pain and nausea dominate the clinical picture. In a literature review conducted by Choong and associates, 89% of the 18 cases that were found presented with abdominal pain. Fevers and rigors may also be found, though usually not in certain patient populations such as the elderly, the immunosuppressed, and diabetics. Two specific, though seldom present, clinical signs are the Deininger sign (decreased pain upon changing from a supine to sitting position)¹³ and vomiting.⁷ Currently, intramural gastric abscess is being diagnosed with increasing frequency by endoscopic ultrasonography.^4,10 On ultrasound, it appears as a well-defined hypoechoic mass within the gastric wall. In addition, there is increased vascularity around the mass on the color Doppler images.¹⁵ Upper gastrointestinal series may show a filling defect suggestive of submucosal mass.¹⁶ On CT, the lesion appears as a localized area of mural thickening within the stomach wall, and fluid and air may also be seen within the mass.^13,17

Until recently, the recommended therapy for intramural gastric abscess was gastrectomy in combination with antibiotics. However, technical advances currently allow either radiologic or endoscopic intervention. Endoscopic drainage with or without antibiotics has been shown to be effective.^{10,15,18–20} In our case, endoscopic drainage was performed during EUS using a plastic stent. Due to the recurrent nature of the patient's disease, she underwent gastrectomy with Roux-en-Y gastrojejunostomy and has since done well. Percutaneous drainage has also been reported to be successful.¹¹ Although one report described successful treatment of a patient with diffuse SG with antibiotics alone, this approach should be regarded with caution.²¹ In the review conducted by Choong and colleagues, there was a 100% survival rate for patients treated with surgery or endoscopic/percutaneous drainage with or without antibiotics (Table 1).

Table 1.

Treatment and Survival Rates for 18 Patients With Intramural Gastric Abscess

	Patients
	Treatment rate		Survival rate
Treatment	No.	%	No.	%
Surgery	11	61	11	100
Endoscopic drainage ± antibiotics	4	22	4	100
Percutaneous drainage ± antibiotics	2	11	2	100
Antibiotics alone	1	6	0	0

In conclusion, the diagnosis of intramural gastric abscess is not difficult to confirm but requires a high degree of suspicion because of its rarity. Early diagnosis is important, as it may obviate a needless gastrectomy and even death.