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.

Intravenous Metoclopramide to Improve the Success Rate of Blind Bedside Post-pyloric Placement of Feeding Tube in Critically Ill Children: A Randomized, Double-Blind, Placebo-Controlled Study

Objective: Impaired gastric emptying is a common cause of delayed feeding in critically ill children. Post-pyloric feeding may help improve feeding intolerance and nutritional status and, hence, contribute to a better outcome. However, post-pyloric feeding tube insertion is usually delayed due to a technical difficulty. Therefore, prokinetic agents have been used to facilitate blind bedside post-pyloric feeding tube insertion. Metoclopramide is a potent prokinetic agent that has also been used to improve motility in adults and children admitted to intensive care units. The objective of this study was to determine the efficacy of intravenous metoclopramide in promoting the success rate of blind bedside post-pyloric feeding tube placement in critically ill children. Design: The design of this study is randomized, double blind, placebo controlled. Setting: The setting of the study is a single-center pediatric intensive care unit. Patients: Children aged 1 month-18 years admitted to the pediatric intensive care unit with severe illness or feeding intolerance were enrolled in this study. Intervention: Patients were randomly selected to receive intravenous metoclopramide or 0.9% normal saline solution (the placebo) prior to the tube insertion. The study outcome was the success rate of post-pyloric feeding tube placement confirmed by an abdominal radiography 6-8 h after the insertion. Measurements and Main Results: We found that patients receiving metoclopramide had a higher success rate (37/42, 88%) of post-pyloric feeding tube placement than the placebo (28/40, 70%) (p = 0.04). Patients who received sedative drug or narcotic agent showed a tendency of higher success rate (p = 0.08). Conclusion: Intravenous metoclopramide improves the success rate of blind bedside post-pyloric placement of feeding tube in critically ill children. Trial Registration: Thai Clinical Trial Registry TCTR20190821002. Registered 15th August 2019.

Nasojejunal Feeding Is Safe and Effective Alternative to Feeding Jejunostomy for Postoperative Enteral Nutrition in Gastric Cancer Patients

Background and Aim  Carcinoma of the stomach is one of the leading causes of mortality worldwide. Surgery for gastric cancer in the form of total or distal gastrectomy is definitive treatment. Feeding jejunostomy (FJ) though improves postoperative nutritional status and outcome, it is not devoid of its complications. In this study, we present the outcomes of nasojejunal (NJ) feeding and FJ and complications associated with them.

Materials and Methods  It is both retrospective and prospective observational study in patients with gastric cancer undergoing surgery. Patients were divided into two groups: those who underwent FJ and those who underwent NJ route of feeding placed intraoperatively.

Results  A total of 279 patients of gastric cancer who underwent surgery were taken into study, of which, 165 were male and 114 females. FJ was done in 42 and NJ in 237 patients, respectively. Gastrectomy + NJ was done in 128 patients, gastrectomy + FJ in 27 patients, gastrojejunostomy + NJ in 109 patients, and FJ in 15 patients. We had three patients of bile leaks in FJ group, of which one patient had intraperitoneal leak who needed re-exploration; rest of the two had peri-FJ external leaks, who were managed conservatively. Most of the complications of NJ group were minor.

Conclusion  Our study of 279 patients in gastric cancer has shown that FJ is sometimes associated with major complications with increased hospital stay and morbidity when compared with NJ tube feeding without any difference in nutritional outcomes. Hence, NJ route of postoperative enteral nutrition can be considered as an alternative to FJ wherever feasible in view of its technical safety and minor complications and morbidity.