Phlegmonous gastritis: case report and review

Phlegmonous gastritis: Review of the pathophysiology

Phlegmonous gastritis is a rare infection of the gastric wall. Clinical presentation of phlegmonous gastritis is generally non-specific and includes epigastric pain, nausea, vomiting and fever. The infection results from a transmural infection of the stomach. Several possible routes for phlegmonous gastritis have been proposed: a direct spread from the injured gastric mucosa site, a hematogenous spread to the stomach from a distant focus and lymphatic spread from a contiguous septic focus. The possibility that swallowing Streptococcus-containing secretion is also mentioned. We present a case of phlegmonous gastritis following a pharyngitis and discuss the routes of phlegmonous gastritis, the possible link to pharyngitis and review the diagnosis and treatment of this condition.

[Infectious Gastric Diseases Other than Helicobacter]

In addition to Helicobacter pylori, the acute bacterial causes of infectious gastritis, include phlegmonous gastritis, gastric tuberculosis, and gastric syphilis. Bacterial gastritis often improves with appropriate broad-spectrum antibiotics, emphasizing the need for prompt diagnosis and treatment based on the clinical and endoscopic findings. Among viral gastritis, cytomegalovirus gastritis, primarily occurring in immunocompromised patients, necessitates antiviral intervention, while immunocompetent individuals typically achieve amelioration by administering proton pump inhibitors. In contrast, most gastric infections caused by the Epstein-Barr virus (EBV) are asymptomatic, but an EBV infection is a cause of stomach cancer. EBV-associated gastric cancer exhibits distinct clinical, pathological, genetic, and post-genetic mutation features, making it clinically significant. The colonization of Candida albicans in the stomach is uncommon, and typical antifungal treatment is unnecessary. Candida infections in gastric ulcers can be treated with anti-ulcer treatment alone. Lastly, anisakidosis in the stomach, which occurs when consuming raw seafood, can manifest in various clinical presentations and is typically treated through endoscopic removal of the nematode. This article aims to contribute to the rapid diagnosis and treatment of rare stomach infections beyond Helicobacter pylori in real clinical situations.

Optimal Management of Patients with Phlegmonous Esophagitis: A Systematic Review and Meta-Analysis

GOALS

To assess the characteristics and prognosis-influencing factors of phlegmonous esophagitis, a rare condition marked by suppurative inflammation of the esophageal submucosa and muscular layers.

BACKGROUND

Effective management strategies for phlegmonous esophagitis are lacking. This study aims to systematically review cases to better understand the disease's features and prognostic determinants.

METHOD

A systematic search was performed using PubMed/MEDLINE and Google Scholar from inception to 20 April 2023. Phlegmonous esophagitis case reports and studies with patient information were included; clinical manifestations, laboratory results, imaging findings, other diagnostic findings, and outcomes were analyzed. A pooled analysis was performed to investigate mortality-related risk factors.

RESULTS

A total of 35 cases of phlegmonous esophagitis were selected from 31 case reports and 2 case series (median age, 57.0 years; male, 54.3%). The patients presented various clinical symptoms, with neck-to-epigastric pain and dysphagia being the most common. Comorbid diabetes mellitus was a major predisposing factor; one-third of the patients had no previous medical history. Computed tomography (CT) and endoscopic examinations were predominantly used for phlegmonous esophagitis diagnosis. Radiological findings showed that the upper and middle esophagus were most frequently involved. Treatments included administration of broad-spectrum antibiotics and drainage via endoscopy or surgery. There were three cases of mortality, and non-survivors tended to have shorter hospital stays, indicating rapid disease progression. In logistic regression, thoracic surgery was a significant mortality-related risk factor (odds ratio, 19.30; 95% confidence interval, 1.33-282.00, p = 0.03).

CONCLUSION

Advancements in CT and endoscopy have led to less-invasive diagnostic and treatment methods for phlegmonous esophagitis. Endoscopic localized abscess treatment is associated with positive outcomes.

Treatment of phlegmonous esophagitis in various patients: a case series

Acute phlegmonous esophagitis (APE) is a rare and fatal disease. Phlegmonous infection involves the submucosal layer and muscularis propria but not the mucosal layer. Because surgery is not the first treatment option for this disease, an accurate diagnosis is crucial. Herein, we report three cases of APE with various clinical features. All patients were successfully treated with antibiotics and appropriate medical procedures.

A Rare Case of Phlegmonous Gastritis in a Previously Healthy Male: A Case Report

Though rare, phlegmonous gastritis (PG) is a serious and life-threatening infection of the gastric submucosa and mucosa. Many factors have been associated with PG, including malignancy, chronic alcohol use, and immunocompromised states. Clinical presentation of PG is often non-specific, and diagnosis is often delayed. Early recognition and starting antibiotics significantly reduce overall mortality. We describe a case of a previously healthy male who presented with moderate abdominal pain and was found to have PG that was treated with an extensive course of antibiotics and total parental nutrition. Contrary to previously described cases in the literature, our patient had no predisposing factors, highlighting the importance of suspecting PG even in the absence of such factors and demonstrating the effectiveness of antibiotics in this disease.

Phlegmonous Gastritis in a Patient With Nonalcoholic Steatohepatitis-Related Cirrhosis: A Case Report and Review of Literature

It is sometimes difficult to diagnose phlegmonous gastritis clinically. We herein present a rare autopsy report of a patient with phlegmonous gastritis associated with nonalcoholic steatohepatitis-related cirrhosis. The patient died of hepatic failure two weeks after exacerbation of anorexia and rapid progression of liver dysfunction. Autopsy revealed cholangitis lenta and sepsis-induced liver dysfunction, which was attributed to phlegmonous gastritis due to Moraxella (Branhamella) catarrhalis. Phlegmonous gastritis has seldom been reported in patients with liver cirrhosis. We believe the importance of keeping in mind that phlegmonous gastritis could be one of the complications of advanced liver cirrhosis.

Phlegmonous gastritis after biloma drainage: A case report and review of the literature

BACKGROUND

Phlegmonous gastritis (PG) is a rare bacterial infection of the gastric submucosa and is related to septicemia, direct gastric mucosal injury, or the direct influence of infection or inflammation in neighboring organs. Here, we present a patient who had spontaneous biloma caused by choledocholithiasis and then PG resulting from bile leakage after biloma drainage.

CASE SUMMARY

A 79-year-old man with a medical history of hypertension had persistent diffuse abdominal pain for 4 d. Physical examination showed stable vital signs, icteric sclera, diffuse abdominal tenderness, and muscle guarding. Laboratory tests showed hyperbilirubinemia and bandemia. Contrast computed tomography (CT) of the abdomen showed a dilated common bile duct and left subphrenic abscess. Left subphrenic abscess drainage revealed bilious fluid, and infected biloma was confirmed. Repeated abdominal CT for persistent epigastralgia after drainage showed gastric wall thickening. Esophagogastroduodenoscopy (EGD) showed an edematous, hyperemic gastric mucosa with poor distensibility. The gastric mucosal culture yielded Enterococcus faecalis. PG was diagnosed based on imaging, EGD findings, and gastric mucosal culture. The patient recovered successfully with antibiotic treatment.

CONCLUSION

PG should be considered in patients with intraabdominal infection, especially from infected organs adjacent to the stomach.

Usefulness of Contrast-Enhanced CT in a Patient with Acute Phlegmonous Esophagitis: A Case Report and Literature Review

Acute phlegmonous esophagitis is a very rare, life-threatening form of esophagitis, characterized by diffuse bacterial infection and pus formation within the submucosal and muscularis layers of the esophagus. We describe a case in which contrast-enhanced chest CT was useful for evaluating the severity of phlegmonous esophagitis, which was overlooked and underestimated by endoscopy.

Phlegmonous gastritis in 2 yearling horses

Phlegmonous gastritis was diagnosed in 2 yearling fillies that were presented with a 1-wk history of fever, lethargy, and hypoproteinemia, associated with a previous diagnosis of equine proliferative enteropathy based on clinical signs and PCR assay detection of Lawsonia intracellularis in fecal samples. Abdominal ultrasound revealed enlargement of the stomach and expansion of its submucosal layer with hypoechoic fluid, as well as thickened hypomotile small intestinal segments. Given the poor prognosis and poor response to treatment, both horses were euthanized, one on the day of presentation and the other after 3 wk of intensive medical management including a combination of antimicrobials, analgesics, and intravenous colloids. At autopsy, acute mural gastritis characterized by severe submucosal edema with suppurative inflammation (i.e., phlegmonous gastritis) and necroulcerative enteritis compatible with the necrotizing form of equine proliferative enteropathy were identified in both horses. The gastric inflammation was associated with thrombosis and mixed bacterial populations, including Clostridium perfringens, that were confined to the submucosa without evidence of mucosal involvement; toxin genes compatible with C. perfringens type C were identified in one case. Human phlegmonous gastritis is an uncommon, often-fatal pyogenic infection that is often associated with mucosal injury, bacteremia, or immunocompromise. Our finding of this unusual gastric lesion in 2 horses with similar signalment, clinical disease, and spectrum of postmortem lesions suggests a similar etiopathogenesis that possibly involves local, regional, or distant hematogenous origin, and should be considered a potential complication of gastrointestinal mucosal compromise in horses.

Gastric wall abscess: A case report and literature review

Background

gastric wall abscess is a rare pathology that is often hard to diagnose and is often associated with poor prognosis. Herein, we report a case of Gastric wall abscess that we managed to treat by endoscopy without the need for surgery which is the usual treatment of choice.

Clinical data

a 50 years old female presented with Epigastric pain. Complete blood count revealed Leukocytosis, neutrophilia and an elevated C-reactive protein. Abdominal CT scan showed a small hypodense area with rim wall enhancement in the pyloric canal. Gastroscopy and endoscopic ultrasound guided drainage was performed and the abscess was drained, content sent for pathology evaluation. Patient was discharged home on antibiotics.

Conclusion

Gastric wall abscess is a rare but important differential diagnosis of Epigastric pain. Endoscopic Ultrasound is the modality of choice to diagnose it. Endoscopic drainage is associated with reduced mortality and morbidity (Soga et al., 2014) [2].

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Gastric wall abscess is a rare pathology of gastric wall with vague presentations.

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Immune-compression, alcohol and diabetes are predisposing factors but some patient may have no such factors.

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The diagnosis of Gastric wall abscess is clinically challenging and it requires a high clinical suspicion.

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Theraputic endoscopic drainage is a promising method to treat it.

Phlegmonous Gastritis and Streptoccocal Toxic Shock Syndrome: An Almost Lethal Combination

We report a case of phlegmonous gastritis in a 70-year-old woman without any predisposing factors, presenting with high fever, epigastric pain, and vomiting complicated by septic shock and multi-organ failure. The ultrasound and the computed tomography scan showed thickening of the stomach wall. Streptococcus pyogenes was isolated in the blood, thereby establishing the diagnosis of streptococcal toxic shock syndrome. An exploratory laparotomy excluded the need for a gastrectomy, and the patient was successfully treated with antibiotics. A short review of phlegmonous gastritis caused by S. pyogenes during the last 12 years is also presented. How to cite this article: Elisabeth P, Cornelia M, Athinna S, Anastasia A, Apostolos A, George D. Phlegmonous Gastritis and Streptoccocal Toxic Shock Syndrome: An Almost Lethal Combination. Indian J Crit Care Med 2021;25(10):1197-1200.

Phlegmonous gastritis: a case series

Background

Phlegmonous gastritis is a rare and fatal infectious disease of the stomach, presenting varied and nonspecific endoscopic images, which are therefore difficult to diagnose. This report discusses three cases of phlegmonous gastritis, each with unique endoscopic images, and considers the differential diagnosis of this disease. These cases were initially suspected of scirrhous gastric cancer, gastric syphilis, and acute gastric mucosal lesion.

Case presentation

Case 1 A 32-year-old Asian man visited our hospital complaining of upper abdominal pain. Endoscopy raised suspicion of scirrhous gastric cancer. However, a histopathological examination showed no malignant cells, thus leading to the diagnosis of phlegmonous gastritis. The patient was started on antibiotic therapy, which was effective.

Case 2 A 33-year-old Asian man visited our hospital complaining of epigastralgia. Endoscopy raised suspicion of gastric syphilis. However, the serum test for syphilis was negative, and Streptococcus viridans was detected in the biopsy specimen culture, which led to the diagnosis of phlegmonous gastritis.

The patient was started on antibiotic therapy, resulting in significant improvement in the endoscopic image after 2 weeks.

Case 3 A 19-year-old Asian man visited our hospital complaining of epigastric pain. Endoscopy raised suspicion of acute gastric mucosal lesion. A gastric juice culture showed Pseudomonas aeruginosa and Streptococcus viridans, thus leading to the diagnosis of phlegmonous gastritis. The patient was started on antibiotic therapy, resulting in the disappearance of the gastric lesions.

Conclusion

In severe cases of phlegmonous gastritis, immediate surgical treatment is generally required. However, the endoscopic images are varied and nonspecific. These three cases suggest that clinicians need to consider the differential diagnosis of phlegmonous gastritis and make accurate diagnoses at an early stage.

Phlegmonous gastritis developed during chemotherapy for acute lymphocytic leukemia: A case report

BACKGROUND

Phlegmonous gastritis (PG) is a rare bacterial infectious disease characterized by neutrophil-based purulent inflammation of the gastric wall. The most representative causative bacterium is Streptococcus pyogenes, followed by Staphylococcus, Pneumococcus and Enterococcus. Hepatic portal venous gas (HPVG) is considered a potentially fatal condition and is rarely associated with PG.

CASE SUMMARY

The white blood cell count of a 70-year-old woman with acute lymphocytic leukemia in complete remission dropped to 100/μL after consolidation chemotherapy. Her vital signs were consistent with septic shock. Venous blood culture revealed the presence of Bacillus cereus. Abdominal computed tomography (CT) and esophagogastroduodenoscopy (EGD) showed marked thickening of the gastric wall. As with the other findings, CT was suggestive of HPVG, and EGD showed pseudomembrane-like tissue covering the superficial mucosa. Histopathological examination of gastric biopsy specimens showed mostly necrotic tissue with lymphocytes rather than neutrophils. Culture of gastric specimens revealed the presence of Bacillus cereus. We finally diagnosed this case as PG with Bacillus cereus-induced sepsis and HPVG. This patient recovered successfully with conservative treatment, chiefly by using carbapenem antibiotics.

CONCLUSION

The histopathological finding of this gastric biopsy specimen should be called "neutropenic necrotizing gastritis".

[Phlegmonous Gastritis Caused by Penetration of a Toothpick]

Phlegmonous gastritis is a disease caused by a bacterial infection of the gastric wall. This condition is rare, but when it does occur, its prognosis appears to be poor. The underlying etiology is largely unknown, but an immunocompromised state is considered an important risk factor. An 85-year-old woman presented with a confused mentality, fever, epigastric pain, and melena. There was no history of alcohol drinking or smoking, nor of previous gastric surgery. On the other hand, there was a history of senile dementia and cognitive impairment. Initial contrast-enhanced abdominal CT revealed gastric wall edema at the antrum with mucosal hyper-enhancement and an abscess in the thickened antrum. Upper gastrointestinal endoscopy on the fourth hospital day showed dark-colored fluid retention in the stomach. The gastric mucosa was inflamed and friable, with several ulcerative lesions showing purulent discharge. A toothpick was found in the process of identifying the base of the ulcerative lesion and was removed. Eventually, phlegmonous gastritis due to the penetration of a toothpick was diagnosed. After endoscopic toothpick removal, the patient's symptoms improved dramatically. Serial endoscopy revealed improvement in the gastric mucosa. This case is an example of phlegmonous gastritis caused by a foreign substance in the gastric wall of a patient with senile dementia. During upper gastrointestinal endoscopy in this case, identification of the base of ulcerative lesion played a critical role in the diagnosis.

A rare case of emphysematous gastritis caused by Lactobacillus fermentum in a patient with diabetes

A 42-year-old man with a history of type 2 diabetes mellitus (complicated by end stage renal disease on peritoneal dialysis) and chronic diarrhea was admitted to the emergency department for having an exacerbation in the number of evacuations. The patient was hypotensive and lethargic. Arterial blood gases were obtained and reported pH 7.39, PaO2 74.5 mmHg, PaCO2 34.9 mmHg, HCO3 21.1 mmol/L, lactate 1.9 mmol/L. He received intravenous fluids resuscitation and was stabilized. His physical examination was notable for somnolence and dehydration. Infectious diseases were ruled out (C. difficile toxin, bacterial and viral gastroenteritis and protozoa infestation) and the patient was transferred to inpatient ward to continue the approach of his chronic diarrhea. On his seven day of hospitalization, the patient presented intense abdominal pain irradiated to right shoulder, hypotension and delirium. Dialysis fluid analysis showed WBC count of 3200/ml (80% neutrophils); cultures were positive for Lactobacillus fermentum. An abdominal CT with intravenous contrast showed gastric wall with intramural gas and pneumoperitoneum (Fig. 1a), which prompted a total gastrectomy with esophago- jejunal anastomosis and Roux-Y loop reconstruction. Surgery found extensive gastric necrosis (Fig. 1b). He was admitted to the intensive care unit and he was started on meropenem, anidulafungin and norepinephrine as a vasopressor. He was weaned of vasopressors and extubated on the eleventh day of hospitalization. Histopathological analysis of the resected stomach showed necrosis, inflammatory debris and gastric mucosa with an intense neutrophil infiltrate (Fig. 1c), without identifying the perforated area. Histopathological report showed intramural Gram-positive rods (Fig. 1d). The patient developed abdominal sepsis and received IV antibiotics. His course was complicated with septic shock and the patient died 5 weeks after his admission. To our knowledge, this is the first case of emphysematous gastritis associated with Lactobacillus fermentum.

Combination of antibiotics, gastric lavage and nasojejunal feeding-an effective alternative for the management of acute phlegmonous gastritis: a case report

Background

Phlegmonous gastritis is a rare bacterial infection of the gastric wall, characterised by purulent inflammation of the gastric mucosa, submucosa and muscularis layers. Phlegmonous gastritis has a high mortality rate, even with correct diagnosis and antimicrobial therapy.

Case presentation

A 22-year-old man presented for acute epigastric pain associated with aqueous diarrhoea, vomiting and sustained fever. Abdominal computed tomography showed diffuse oedema and thickened gastric wall, increased number and size of abdominal lymph nodes and the absence of pneumoperitoneum. Fibregastroscopy revealed oedematous, ridged and thickened gastric mucosa with abundant purulent secretion, especially in the antrum, consistent with phlegmonous gastritis, which was confirmed by histological evaluation of gastric biopsies. Cultures of the tissue biopsies and purulent secretion were positive for Enterococcus cecorum. He was treated with sensitive antibiotics according to the antibiogram, and importantly, with continuous gastric lavage and individualised nutritional support therapy. He eventually recovered well and was discharged with no abdominal symptoms.

Conclusions

Our case indicates that early diagnosis and immediate treatment are crucial to achieve positive outcomes. The combination of sensitive antibiotics, gastric lavage and early enteral nutrition via nasojejunal feeding might be an effective alternative for the comprehensive treatment of acute phlegmonous gastritis.

Phlegmonous Gastritis: A Case Report of Successful Early Antibiotic Treatment

Phlegmonous gastritis (PG) is a rare and serious bacterial infection of the gastric submucosa. Diagnosis is often delayed due to nonspecific symptoms, but if recognized early, PG may be treated successfully with medical therapy alone. We describe a case of a 47-year-old patient admitted with gastrointestinal symptoms and sepsis. He was found to have beta-hemolytic streptococcus bacteremia with a purulent gastric ulcer on endoscopic evaluation, consistent with the diagnosis of PG. Though surgical evaluation is often required in cases of PG, our patient quickly improved with parenteral antibiotic therapy. This case highlights an uncommon source of sepsis and demonstrates the success of antibiotic monotherapy with early recognition.

A case of phlegmonous gastritis after acute pharyngitis

We report a case of phlegmonous gastritis that followed an episode of acute pharyngitis. A 21-year-old man visited our emergency room because of intense epigastric pain. Fourteen days before the visit, he had symptoms of a sore throat and high fever. He was diagnosed with acute pharyngitis and treated with antibiotics. Although the symptoms of acute pharyngitis were relieved, epigastric pain began 5 days before the emergency visit. Computed tomography showed diffuse gastric wall thickening, and emergent esophagogastroduodenoscopy revealed diffusely spreading hyperemic mucosa with multiple erosions. He was admitted with a diagnosis of acute phlegmonous gastritis and was treated with antibiotics. The antibiotic treatment was effective and resulted in resolution of his clinical symptoms and normalized C-reactive protein concentrations. On hospital day 29, he was discharged. However, he was re-admitted because of recurrence of phlegmonous gastritis 5 days after discharge and 15 days after finishing the antibiotics. Cultures of gastric biopsies and juice were both positive for Streptococcus constellatus/milleri. Antibiotic treatment was effective, and he recovered without recurrence. A possible association between upper respiratory infections and subsequent phlegmonous gastritis has been reported, and this case supports causality. However, further studies are needed to evaluate causality and pathogenesis.

Phlegmonous gastritis complicated by abdominal compartment syndrome: a case report

BACKGROUND

Phlegmonous gastritis (PG) is a rare, suppurative bacterial infection of the gastric wall, which may rapidly evolve into fatal septicemia. The etiology and pathogenesis are poorly understood; however, multiple risk factors have been cited in current literature. Most cases have been diagnosed at autopsy, and occasionally at laparotomy, as the clinical presentation is often variable.

CASE PRESENTATION

We report a case of a 67-year-old male presenting with intractable nausea, vomiting, and epigastric pain following an uneventful upper gastrointestinal (GI) endoscopy. Diagnostic workup including contrast tomography (CT) and endoscopic assessment was in keeping with PG. This was subsequently followed by development of abdominal compartment syndrome (ACS) and clinical deterioration necessitating surgical resection of the stomach.

CONCLUSION

This case emphasizes the importance of early diagnosis of this potentially fatal infection that can follow endoscopic procedures and illustrates ACS and septic shock as serious complications. There is currently no consensus on the proper management of PG; however, in this case, a combination of surgery and antibiotics provided a favourable outcome. Limited number of cases of PG have been reported in literature, and to our knowledge, this is the first reported case of PG with subsequent ACS as an acute complication.

Acute Phlegmonous Gastritis Complicated by Subphrenic Abscess

BACKGROUND

Phlegmonous gastritis (PG) is a rare and potentially fatal disease characterized by bacterial infection of the gastric wall. However, its clinical features are nonspecific, which may delay its diagnosis and treatment.

CASE REPORT

We report a case of a previously healthy 53-year-old woman with localized PG complicated by subphrenic abscess formation who was treated successfully with antibiotics and percutaneous catheter drainage. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early diagnosis and treatment initiation are important to improving outcomes. Emergency physicians should consider PG a differential diagnosis of acute abdomen.

Acute suppurative oesophagitis with fever and cough: A case report

BACKGROUND

Suppurative oesophagitis is a diffuse inflammation of the oesophagus characterized by suppurative exudate or pus formation. Suppurative infections can affect any part of the gastrointestinal tract, most commonly the stomach, with inflammation involving the entire gastric cavity. However, cases extending beyond the cardia or pylorus and involving the oesophagus, small intestine, and colon are rare. Usually such cases are discovered during surgery or autopsy.

CASE SUMMARY

We report a rare case of acute suppurative oesophagitis. A 57-year-old man presented at the Emergency Department of our hospital with fever and productive cough. The patient had a significant history of lower oesophageal mucosal frostbite. He was successfully diagnosed and treated with repeated gastroscopy, appropriate antibiotics, and innovative symptomatic treatment.

CONCLUSION

Early diagnosis and appropriate treatment of acute suppurative oesophagitis are critical. Nutritional support, postural drainage, and other symptomatic treatments must be considered.

More than Just a Hole in the Wall: Evolving Management and Treatment Paradigms of Suppurative Gastritis

Suppurative gastritis is an uncommon lesion and often an occult cause of upper abdominal pain without florid signs of a septic focus. There are two main phenotypic forms: (1) localized, also referred to as gastric abscess; and (2) diffuse, in which the differential diagnosis includes a more diverse range of benign and malignant lesions. Cross-section imaging such as CT allows for rapid diagnosis and demonstrates the location and extent, but not the specific etiology, of the lesion. High-frequency endoscopic ultrasound (EUS) and fine needle aspiration (FNA) have greatly improved the safety and diagnostic accuracy of suppurative gastritis. EUS/FNA provides an opportunity to arbitrate among infectious and malignant or benign tumors, to identify specific pathogens, and in cases of localized gastric abscesses, for resolution by decompression. More advanced endoscopic procedures are rapidly emerging to supplement EUS/FNA, which already demonstrate the promise of improved, minimally-invasive diagnosis and effective management for the diverse range of lesions causing suppurative gastritis.

Gastric lymphoma complicated by phlegmonous gastritis and Guillain-Barré syndrome: A case report

INTRODUCTION

Complications such as severe infection may occur during the chemotherapy of malignant lymphoma. Phlegmonous gastritis (PG) is a rare acute bacterial infection associated with high mortality, requiring early diagnosis, and prompt management. In addition, Guillain-Barré syndrome (GBS) occasionally requires early treatment and intensive care management due to the occurrence of severe neuropathy and respiratory failure.

PATIENT CONCERNS

A 70-year-old male was diagnosed with primary gastric diffuse large B-cell lymphoma (DLBCL) after the detection of several polypoid tumors with ulcers. The patient underwent chemotherapy for DLBCL and exhibited adverse effects (i.e., fever, vomiting, epigastric pain, and neutropenia). Computed tomography indicated widespread thickening in the gastric wall. Furthermore, approximately 2 weeks later, the patient presented with gradual symmetric lower extremity weakness and respiratory failure due to paralysis of the respiratory muscle.

DIAGNOSES

DLBCL was diagnosed through a gastric tumor biopsy. On the basis of the computed tomography findings, a culture of gastric juice, nerve conduction studies, and clinical symptoms, this case of gastric lymphoma was complicated with PG and GBS.

INTERVENTIONS

The patient was treated with antimicrobial therapy and administration of granulocyte colony-stimulating factor for PG, and with intravenous immunoglobulin and intensive care management for GBS.

OUTCOMES

Despite the aggressive progress of the condition, the patient improved without relapse of DLBCL.

CONCLUSION

PG was regarded as a precedent infection of GBS. In this article, we present the first reported case of gastric lymphoma complicated with PG and GBS.

Acute gastric necrosis caused by a -hemolytic streptococcus infection: a case report and review of the literature

Acute necrotizing gastritis, which appears to be a variant of phlegmonous gastritis is the rarest cause of gastric necrosis. We report a case of a 57-year-old female patient with an acute necrotizing gastritis caused by a Group A β-hemolytic streptococcus. The case presented herein is of unusual interest because only a limited number of case reports on this etiology have been published. Diagnosing infectious necrotizing gastritis remains complex because of its rarity and nonspecific clinical presentation. Nevertheless, prompt diagnosis is of high importance because necrotizing gastritis can progress rapidly into a more advanced stage causing septic shock or even death. In our opinion, early resection of necrotic gastric wall combined with adequate antimicrobial therapy is the cornerstone in treatment of necrotizing gastritis. We will present a case in which adequate medical treatment was not successful.

Phlegmonous gastritis in a patient with mixed-phenotype acute leukemia in the neutropenia phase during chemotherapy: A case report

RATIONALE

Phlegmonous gastritis is a rare bacterial infection of the gastric wall with high mortality. However, diagnosis of phlegmonous gastritis is difficult and standard treatment remains unestablished.

PATIENT CONCERNS

We report a 33-year-old male patient with mixed-phenotype acute leukemia who developed acute phlegmonous gastritis during the neutropenia phase on induction chemotherapy and was successfully treated.

DIAGNOSES

The patient was diagnosed with phlegmonous gastritis, which might be caused by Stenotrophomonas maltophilia on the basis of clinical manifestation, physical examination, enhanced computed tomography scan, histological finding, and microorganism culture of biopsied specimen in endoscopy.

INTERVENTIONS

The patient was treated with gastrointestinal decompression and broad-spectrum antibiotics.

OUTCOMES

He recovered from phlegmonous gastritis and received the 2nd cycle of chemotherapy with no complaint of abdominal discomfort.

LESSONS

Early recognition and proper management including broad-spectrum antibiotics are key approaches to phlegmonous gastritis.

A Patient With Good Syndrome Complicated With Phlegmonous Gastritis

Phlegmonous gastritis (PG) is a rare and severe infection, with less than 500 cases reported. Similarly, Good syndrome represents a rare adult-onset immunodeficiency with a prevalence of 1 in 500,000 people. We present the first case of a patient with Good syndrome complicated with PG. Given that up to 50% of patients with PG do not have an identified risk factor, underlying immunodeficiencies should be conscientiously investigated.

A case of phlegmonous gastritis with hepatic portal venous gas caused by Aeromonas hydrophila successfully treated with medication

A 74-year-old woman was admitted to the hospital with epigastric pain, severe nausea and vomiting, and diarrhea that had started 3 days previously. She had eaten raw Ayu fish 4 days before admission. An abdominal contrast-enhanced computed tomography scan revealed the presence of gas in the portal vein and remarkable thickening of the gastric wall. In many cases, the gas in the portal vein indicates the existence of intestinal necrosis. Esophagogastroduodenoscopy showed a submucosal tumor-like elevation in the gastric corpus. She was diagnosed with sepsis and phlegmonous gastritis (PG) with hepatic portal venous gas (HPVG) caused by Aeromonas hydrophila, which was detected in her stool. The patient was treated with antibiotics and discharged from the hospital 23 days after admission in a stable condition. When caused by PG, HPVG is not necessarily considered a poor prognostic factor and is expected to be treatable with medication. However, patients should be closely monitored for signs of a life-threatening pathology such as intestinal necrosis.

Acute Phlegmonous Esophagogastritis Causing Respiratory Distress

Phlegmonous esophagogastritis is an extremely rare condition characterized by diffuse inflammation of the upper gastrointestinal tract, sparing the mucosa. Patients can present with an acute onset of symptoms, and computed tomography scans can show diffusely edematous wall with intramural low attenuation surrounded by ring enhancement. Here we report such a case of a man who presented with central chest pain and breathing difficulty. The patient developed respiratory distress due to compression of trachea by the edematous esophagus.

Streptococcal toxic shock syndrome with primary group A streptococcus peritonitis in a healthy female

A 47-year-old female with a history of chronic alcoholism presented with nausea, vomiting and mild epigastric tenderness. She reported subjective fever, abdominal fullness and loose, watery stools and had stable vitals on arrival. Examination was positive for mild epigastric tenderness with hepatic enlargement. Computed tomography of the abdomen showed circumferential thickening of the stomach wall, lower esophagus and the first part of the duodenum in addition to peritoneal ascites. She was admitted for alcohol-related gastritis, acute alcoholic hepatitis, and acute kidney injury. She was started on fluid resuscitation and supportive management. After 8-hours, the patient became hemodynamically unstable with subsequent intubation and fluid resuscitation. She was started on empiric antibiotics. Blood and ascitic fluid cultures were obtained showing group A beta-hemolytic streptococci (GAS). The patient was diagnosed with primary GAS peritonitis along with diffuse gastritis and streptococcal toxic shock syndrome. No cutaneous source of Streptococcus pyogenes was identified, and there was no personal or family history of streptococcal pharyngitis. Antibiotics were switched to IV ampicillin and clindamycin. However, the patient continued to deteriorate and succumbed to death within 2-days.

Diagnostic challenges in differentiating intramural gastric abscess from gastric cancer: Two case reports

RATIONALE

Intramural gastric abscess is a rare clinical condition. It is frequently neglected because of the absence of specific clinical symptoms and misdiagnosed due to the difficulty in differentiating a benign lesion from a malignant one on the gastric wall. Several imaging techniques are helpful for identifying an intramural gastric abscess. Nevertheless, a definite diagnosis is still challenging, and unnecessary surgery is sometimes performed. Therefore, more information regarding case experiences should be shared to help correctly diagnose intramural gastric abscesses.

PATIENT CONCERNS

Two patients, a 47-year-old woman and a 31-year-old man, were hospitalized for abdominal pain.

DIAGNOSIS AND INTERVENTIONS

In addition to routine blood tests, either two or three imaging examinations, including esophagogastroduodenoscopy (EGD), computed tomography (CT), and endoscopic ultrasonography (EUS), were performed for these patients. The first patient was diagnosed with gastric cancer metastasized to the gastrocolic ligament, and the other was suspected to have a gastric wall abscess secondary to cancer of unknown origin. Both patients underwent surgery.

OURCOMES

Surgery revealed a gastric wall abscess involving the colon in the first patient. She recovered after using oral antibiotics for 1 week, and she showed no discomfort or abnormalities during follow-up examinations. The second patient was diagnosed with gastric wall abscess derived from metastasized gastric cancer with a primary tumor located at the splenic flexure of the colon. He was discharged because of intolerance to chemotherapy and died before follow-up.

LESSONS

EGD, CT, and EUS/fine-needle aspiration (EUS/FNA) are extremely valuable for differentiating an intramural gastric abscess from gastric cancer, and misdiagnoses can occur if any of these assessments is ignored. Hence, we recommend performing EGD, CT, and EUS/FNA as part of the routine examination when either of these two diseases is suspected clinically.

A Case of Phlegmonous Gastritis in a Patient with Psoriatic Arthritis on Infliximab

Phlegmonous gastritis is a pyogenic infection affecting the submucosa of the gastric wall. Although rarely diagnosed, it remains a disease with high mortality. We thereby describe the case of a 42-year-old male patient known for psoriatic arthritis on Infliximab who was diagnosed with phlegmonous gastritis secondary to immunosuppressive therapy. The patient had a favourable outcome with a conservative treatment consisting of a 14-day course of broad antibiotherapy.

Sepsis caused by acute phlegmonous gastritis based on a group A Streptococcus

We present a case of 45-year-old male with acute phlegmonous gastritis (APG) based on a hemolytic group A Streptococcus. APG is a rare and often a potentially fatal disease, which is characterized by a severe bacterial infection of the gastric wall. Because APG is a rapidly progressive disease, it comes with high mortality rates. Patients with an early diagnosis may undergo successful treatment and have a survival benefit. As soon as the diagnosis of APG is suspected, aggressive and adequate antibiotic treatment in combination with surgical intervention should be considered.

Phlegmonous Gastritis: A Report of Three Cases with Clinical and Imaging Features

Phlegmonous gastritis is a rare but often fatal acute pyogenic infection of the stomach. We herein report three cases of phlegmonous gastritis with different causes: the long-term placement of a nasogastric feeding tube, bacteremia associated with cellulitis in a diabetic patient, and an adverse reaction to paclitaxel/carboplatin chemotherapy for cancer of unknown primary cause, which were classified as primary, secondary, and idiopathic types, respectively. Coping with the increasing morbidity rate associated with the diverse background of such patients requires a thorough understanding of the clinical features and image findings associated with this entity.

Diagnosis and treatment of acute phlegmonous gastritis: A case report

RATIONALE

Acute phlegmonous gastritis (PG) is a rare and often fatal condition mainly characterized by severe bacterial infection of the gastric wall. Case reports of PG over the past century average about 1 per year. Early diagnosis and immediate treatment are crucial to achieve positive outcomes.

PATIENT CONCERNS

A 47-year-old man was referred to our hospital because of abdominal pain, high fever, and vomiting for 4 days, with aggravation for 24 hours. Physical examination revealed epigastric abdominal pain, rebound pain, and abdominal wall tightness. Abdominal CT showed thickening of the stomach wall with edema and gas.

DIAGNOSES

On the basis of symptoms and CT imaging findings, the patient was diagnosed with acute PG.

INTERVENTIONS

Antibiotic therapy and operation.

OUTCOMES

The patient immediately underwent an operation after conservative treatment using antibiotics proved ineffective. The whole stomach was obviously swollen, and the anterior side and posterior wall of the stomach were nigrescent necrotic. Hence, total gastrectomy was performed followed by reconstruction (roux-en-y), and pus that accumulated in the stomach wall was cultured. At postoperative broad-spectrum antibiotic coverage, the patient finally recovered.

LESSONS

Acute PG is a rare infection of the gastric wall especially after antibiotic treatment. Given the fast progression of this disease, early recognition and immediate action are crucial to achieve positive outcomes.

Phlegmonous Esophagitis Treated with Internal Drainage and Feeding Jejunostomy

We report the case of a 67-year-old woman presenting with epigastric pain. Computed tomography identified diffuse phlegmonous esophagitis. Esophagogastroduodenoscopy revealed multiple perforations in the mucosal layer of the esophagus. A large amount of pus was drained internally through the gut. The patient was treated with antibiotics and early jejunostomy feeding. Although phlegmonous esophagitis is a potentially fatal disease, the patient was successfully treated medically with only a minor complication (esophageal stricture).

Patterns of Gastric Injury: Beyond Helicobacter Pylori

Gastric biopsies are routinely obtained from patients with symptoms related to the gastrointestinal tract and, as a result, a variety of histologic changes are observed in patients with or without endoscopic evidence of mucosal injury. Although Helicobacter pylori-related gastritis is still common, several other patterns of mucosal injury are increasingly encountered. These patterns of injury are classified based on the nature and distribution of inflammation, location of epithelial cell injury, presence of crystal or pigment deposition, and/or other unique features. This article discusses each of these patterns and provides a differential diagnosis for each.

A Rare Case of Acute Phlegmonous Esophagogastritis Complicated with Hypopharyngeal Abscess and Esophageal Perforation

Patient: Female, 60

Final Diagnosis: Acute phlegmonous esophagogastritis complicated with hypopharyngeal abscess • esophageal perforation

Symptoms: Fever • painful swallowing • chest pain

Medication: —

Clinical Procedure: Drainage • debridement • esophageal reconstruction

Specialty: Surgery

The predictors of mortality and secular changes in management strategies in emphysematous gastritis

BACKGROUND AND AIMS

Emphysematous gastritis (EG) is caused by invasion of the gastric wall by gas-producing organisms and carries mortality rate up to 60%. Our investigation aimed to determine the predictors of survival and the secular trends in survival rates of subjects with EG.

METHODS

PubMed search was completed to identify previous cases of EG. In addition, we included a recent case from our center. Statistical analysis was completed with two-sided Chi² tests for categorical data and t-tests for continuous variables using SPSS v. 22.0 (SPSS Inc, Chicago, IL).

RESULTS

Study cohort included 59 adults. Mean age was 55.5 years; mean LOS was 28.6 days, and 44.1% of subjects were female. Subjects who had EG before 2000 had significantly higher rates of exploratory laparotomy compared to subjects who had EG after 2000 (62.5% vs. 22.2%, P=0.002). In contrast, subjects with EG after 2000 had significantly higher rates of EGD (55.6% vs. 18.8%, P=0.003) and lower rates of mortality (33.3% vs. 59.4%, P=0.046) compared to subjects with EG on or before 2000. In multivariate logistic regression analysis, the only independent predictor of mortality was length of stay (P=0.047).

CONCLUSION

We showed that previously reported 60% mortality rate of EG has been reduced to 33.3% for cases reported after 2000. EGD has been utilized more often while surgical interventions are used only in carefully selected cases. Our data suggests that early endoscopic evaluation and optimal medical management can perhaps continue to improve survival in subjects with EG.