Acute phlegmonous gastritis

Acute phlegmonous gastritis: A case report

Acute phlegmonous gastritis (APG) is an extremely uncommon and potentially rapid fatal systemic infection with very few reported cases in the literature. This case report demonstrates a case of idiopathic APG in an afebrile, otherwise healthy individual that resolved with broad-spectrum antibiotic therapy and did not require operative management.

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.

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.

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.

Acute gastric necrosis after routine oesophagogastroduodenoscopy with therapeutic argon plasma coagulation

A 56-year-old woman presented to the accident and emergency department with peritonitis 2 days after a routine oesophagogastroduodenoscopy. She was taken to theatre with the finding of gastric necrosis. Blood and peritoneal cultures grew group A haemolytic Streptococcus. Histology revealed normal vasculature, no volvulus but marked neutrophilia in the submucosa with an intact mucosa. The stomach was resected and the patient recovered in the intensive care unit but overwhelming acidosis progressed to multiorgan failure and treatment was eventually withdrawn. Acute phlegmonous gastritis has been well described in the literature but mainly before the advent of antibiotics. The most common organism is group A haemolytic Streptococcus (commonly found in throat infections) and predisposing factors include instrumentation. Should antibiotics be given at the start of an oesophagogastroduodenoscopy and should routine procedures be delayed if active upper respiratory tract infections are present?

Phlegmonous gastritis and group A streptococcal toxic shock syndrome in a patient following functional endoscopic sinus surgery

BACKGROUND

Phlegmonous gastritis is a rare and often fatal condition that can affect healthy individuals in 50% of cases. The condition has been described in accounts dating back to the pre-antibiotic era, during which time mortality was nearly 100%. Over the past century, case reports average about one per year. The etiology remains unclear, although Streptococcus species is isolated frequently. The optimum treatment has not been delineated clearly but likely involves a combination of antibiotics with or without surgical resection.

METHODS

A case report was presented and the pertinent literature was reviewed.

CASE REPORT

A 45-year-old man with a history of recent paranasal sinus surgery presented with acute abdominal pain and criteria consistent with toxic shock syndrome. Computed tomography scan showed diffuse thickening of the gastric wall and free intraperitoneal fluid. Exploratory laparotomy revealed a thickened stomach wall with outer fibrinous exudate and murky peritoneal fluid, which grew Streptococcus pyogenes. Intraoperative esophagogastroduodenoscopy revealed thickened gastric folds with a "cobblestone" appearance and no evidence of perforation. He was treated with antibiotics intravenously and sustained a difficult intensive care unit course complicated by ventilator-dependent respiratory failure, renal failure, and coagulopathy, but survived without major disability.

CONCLUSIONS

This is an unusual case presentation of a rare but potentially lethal condition, whose optimal treatment is unclear. Phlegmonous gastritis should be considered when isolated gastric wall thickening is encountered in the clinical setting of toxic shock syndrome.

Pathology of non-Helicobacter pylori gastritis: extending the histopathologic horizons

The development of modern endoscopic techniques, easier and greater access to healthcare, and interest in Helicobacter pylori infection and its implications have all led to a significant increase in upper endoscopies. In turn, gastroenterologists and pathologists have been recognizing an ever-increasing number of patterns of mucosal injury. Consequently, there is now an interest in a wider aspect of non-neoplastic gastric pathology, namely, non-HP (H. pylori) gastritis. In this review, we present major clinico-pathological entities, based on either the salient morphological features or the underlying etiologies.

Phlegmonous gastritis in a 32-week pregnant woman managed by conservative surgical treatment and antibiotics

Phlegmonous gastritis is an extremely rare and life-threatening condition. We report the case of a 32-week pregnant women presenting a peritonitis owing to phlegmonous gastritis caused by a group A streptococcus and successfully managed by conservative surgical treatment and antibiotics. Multiple endoscopies with biopsies illustrate progressive and complete gastric recovery.

Gastritis from NSAIDS to Helicobacter pylori

Gastritis is a histologic diagnosis. To understand gastritis, the radiologist must have some working knowledge of gastric histology and pathology. Therefore, this article first describes normal histologic and radiologic anatomy. The pathology of gastritis is then presented to give the radiologist a basis for understanding the radiologic findings. Finally, gastritis is discussed from a clinical and radiologic perspective.

Primary peritonitis due to group A streptococcus

Primary peritonitis is a rare condition occurring, by definition, in patients without underlying causes, such as perforated viscus, pre-existing ascites, or nephrosis. We report a case of primary peritonitis and shock due to group A beta-hemolytic streptococcus, a rare etiology. A review of the world's literature shows a predilection for women to have this condition. The entry site is obscure in most cases. Asymptomatic genital tract colonization may be a portal of entry in some women. Shock or toxic shock syndrome often accompany the abdominal findings. Laparotomy to exclude a perforated viscus may be unavoidable. Despite the significant morbidity, expeditious and appropriate antibiotic therapy is curative.

Peptic ulcer disease in children

A peptic ulcer in a child looks the same as it does in an adult, and many of the aetiologies of peptic ulcer disease in children are similar to those in adults. However, there are many differences between children and adults, especially in the areas of clinical presentation, the prevalences of different types of ulcer disease, and the prevalence of complications of ulcer disease. Therefore the approach to diagnosis and management in children is often at variance with that in adults. One important example is the approach to suspected Helicobacter pylori (H. pylori) disease in children, in which consensus groups have advised a considerably different approach in children. While the chapter deals with the full range of peptic ulcer disease in children, the focus is on those aspects in which there are differences between adults and children.

Two cases of idiopathic acute gastric necrosis

Two cases of acute hemorrhagic gastric necrosis are presented. The first patient was a 62 yr old man with a past history of chronic gastritis, Parkinson's disease and dementia. The second case was a 25 yr old woman with recent abuse of oral analgesic agents. Both presented with an acute abdomen and peritonitis, and underwent urgent gastrectomy for gastric necrosis with perforation. The first patient died, whereas the second recovered. Histology of the gastrectomy specimens showed severe hemorrhagic transmural gastric necrosis with minimal inflammatory changes. Only occasional Gram positive rods were seen in case 1, and microbiological cultures were negative. The etiology of the gastric necrosis in these 2 cases is unclear.

Phlegmonous gastritis: an unusual presenting symptom of Sjögren's syndrome

This case report describes the histological and macroscopic changes seen within a few months in the gastric mucosa of a 28 year old woman patient with upper abdominal symptoms. With hindsight these changes were the first signs of Sjögren's syndrome.

Phlegmonous gastritis associated with HIV-1 seroconversion. Endoscopic and microscopic evolution

A 40-year-old man presented with peritonitis. Diagnosis of phlegmonous gastritis was made by laparotomy. Conservative treatment combined with antibiotics was successful. Multiple endoscopies with biopsies illustrate the natural history of this disease. The patient developed HIV-1 seroconversion during hospital stay. Prompt diagnosis and treatment may improve the prognosis of this often lethal disease.