Article Search
검색
검색 팝업 닫기

Metrics

Help

  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

  • 2. Editorial Board

    Editor-in-Chief + MORE

    Editor-in-Chief
    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
  • 3. Editorial Office
  • 4. Articles
  • 5. Instructions for Authors
  • 6. File Download (PDF version)
  • 7. Ethical Standards
  • 8. Peer Review

    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
    The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.

    The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.

Search

Search

Year

to

Article Type

Case Report

Split Viewer

A Case of Intramural Gastric Wall Abscess, a Rare Disease Successfully Treated with Endoscopic Incision and Drainage

Kyung Rok Kim , Ki Nam Shim , A Reum Choe , Min Jong Lee , Ye Hyun Park , Eun Mi Song , Chung Hyun Tae , Sung Ae Jung

Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea

Correspondence to: Kyung Rok Kim
ORCID https://orcid.org/0000-0003-3778-0058
E-mail dkflak80@gmail.com

Received: March 9, 2022; Revised: May 27, 2022; Accepted: June 10, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2023;17(6):949-953. https://doi.org/10.5009/gnl220009

Published online January 26, 2023, Published date November 15, 2023

Copyright © Gut and Liver.

Gastric wall abscess is a rare condition characterized by a purulent inflammatory process resulting in the formation of a pocket of pus in the stomach. As the mucosa is usually intact, it requires various tools such as endoscopic ultrasonography or computed tomography for the differential diagnosis to rule out more common subepithelial tumors. Even after the diagnosis, the treatment for gastric wall abscess was previously restricted to surgical resection in combination with antibiotics. Currently, in order to avoid unnecessary surgery, the alternative method of initial treatment with an endoscopic approach is recommended. It also helps to choose appropriate antibiotics with confirmation of the pathogen by drainage. There are few reports that describe the detailed processing of the endoscopic drainage, and there is no consensus on the treatment. The pathogens that cause gastric wall abscess are usually Streptococci, Staphylococci, and Escherichia coli. There is only one case reported to be caused by Candida albicans. This is the first report of Elizabethkingia anopheles as the pathogen of the gastric wall abscess. Here, we report a case of gastric wall abscess in a 75-year-old man, safely treated by endoscopic drainage and antibiotics, confirmed by isolating the contents of the abscess.

Keywords: Abdominal abscess, Phlegmon, Suction drainage, Case reports

Gastric wall abscess is a rare disease and difficult to diagnose. Due to the characteristics of the abscess, it is difficult to culture and the therapeutic effect of empirical antibiotics can be restricted. Until now, most gastric abscess required surgical intervention if there was no response to empirical antibiotics. However, endoscopic approach is emerging as an alternative method. Here we report a unique case of gastric wall abscess treated by endoscopic drainage and specified antibiotics by culture results. The patient provided written informed consent for the publication.

A 75-year-old man visited a primary medical clinic, presenting with epigastric pain, anorexia, and vomiting. He had a history of hepaticojejunostomy due to calculous cholecystitis. He was referred to our hospital and admitted for further evaluation of the mass found on the abdominal ultrasound. In the initial laboratory results, the white blood cell count was 10,550/mL and C-reactive protein level was elevated to 4.25 mg/dL (normal range, <0.05 mg/dL). Computed tomography (CT) of the abdomen identified about 4 cm sized low-density mass-like lesion with peripheral enhancement which invaded the gastric antral submucosa, which was compatible with abscess (Fig. 1A). A 6.4-cm-sized large mass with multiple small nodular lesions in peripheral portion compatible with abscess was detected in the left lateral segment of the liver. Later, the mass in the liver was diagnosed as intrahepatic cholangiocarcinoma by ultrasound-guided liver biopsy and positron emission tomography/CT. Treatment for gastric abscess with empirical broad-spectrum antibiotics (intravenous [IV] ceftriaxone 2 g every 24 hours) was initiated. Despite treatment, during the first 4 hospital days, his pain did not improve and fever up to 38.8°C developed. White blood cell increased to 16,480/mL and the C-reactive protein level increased to 6.66 mg/mL, but there was no growth in the blood culture. We changed antibiotics (meropenem 1 g IV every 12 hours) and performed an esophagogastroduodenoscopy with endoscopic ultrasonography (EUS). Esophagogastroduodenoscopy showed a huge subepithelial tumor (Fig. 1B) and EUS showed about 4.3×2.5 cm sized homogenous mass with mixed echo from the third layer at the anterior wall of the antrum, which filled with liquified material, and air fluid level was noted (Fig. 1C). We performed endoscopic incision and drainage immediately. After the injection of saline (Fig. 2A), about 1.5-cm-sized incision up to the submucosal layer was done by H-knife (Clear-Cut Knife H type, Finemedix Co., Ltd., Daegu, Korea) (Fig. 2B). Clear fluids gushed out from the opening (Fig. 2C). An endoscopic retrograde cholangiopancreatography catheter was introduced to the opening to the abscess pocket, and aspiration was done for the culture studies (Fig. 2D). About 20 mL of saline irrigation into the lesion was done. After the procedure, the lesion was markedly collapsed (Fig. 2E). Over the following 3 days, dramatic improvement of epigastric pain was achieved. The culture from the drained fluid detected Elizabethkingia anopheles (resistant to cefepime, ceftazidime, and meropenem; sensitive to ciprofloxacin and trimethoprim/sulbactam) and Candida albicans. We added ciprofloxacin (400 mg IV every 12 hours) and fluconazole (400 mg IV every 24 hours) during the hospital stay. Previous leukocytosis became normal at 4,810/mL and the C-reactive protein level decreased to 0.59 mg/dL. Finally, the patient restored appetite when he was discharged after 10 days after endoscopic incision and drainage. In the outpatient department, he received oral ciprofloxacin (500 mg twice a day) and proton pump inhibitor (esomeprazole 20 mg once a day) and planned surgery for the cholangiocarcinoma.

Figure 1.The radiologic and endoscopic features of case. (A) The gastric wall abscess with submucosal invasion of the antrum was seen (arrow). (B) Huge subepithelial tumor was seen at the anterior wall of the antrum. (C) Mass arising from the third layer was filled with liquified material.

Figure 2.The endoscopic procedures of the intramural gastric wall abscess. (A) The site of epinephrine and saline mixture injection. (B) The endoscopic incision was done by an H-knife, (C) clear fluids gushed out immediately. (D) Aspiration and irrigation was done by an endoscopic retrograde cholangiopancreatography catheter, and (E) the lesion was markedly collapsed.

An intramural gastric abscess is a localized form of phlegmonous gastritis.1 The most common manifestation of phlegmonous gastritis is the diffuse involvement of the gastric submucosa extending into all layers of the gastric wall. A localized form is relatively rare, accounting for 5% to 15% of all phlegmonous gastritis.2 A purulent inflammatory process results in the forming of a pocket of pus, usually in the antrum and pylorus, but it can develop in any location of the stomach.3 The submucosa of the involved lesion may be thickened, and the flattened mucosa almost looks intact, so we need to rule out subepithelial tumors such as gastrointestinal stromal tumors.4

As the pathogenesis of phlegmonous gastritis is unknown, the cause of the intramural gastric abscess is not certain. The possible causes are the direct bacterial invasion through the damaged gastric mucosa. Another source can be an infection by lymphatic or hematogenous dissemination.2 To the best of our knowledge, the most common pathogens are Streptococci, Staphylococci, and Escherichia coli.4 In this case, C. albicans and E. anopheles were cultured. C. albicans are rarely reported as the pathogen, but this is the first report of E. anopheles as the pathogen of the gastric wall abscess.

First described in 2005, Elizabethkingia (nosocomial infection Gram-negative Chryseobacterium) infections are rare. It is an emerging bacterial pathogen for nosocomial condition since 2016.5 E. anopheles was first isolated from the midgut of the Anopheles gambiae mosquito in 20116 and is the most frequently isolated Elizabethkingia species in recent clinical studies. It has natural resistance to carbapenems and a variety of potential infection sources, including healthcare products, water sources and the environment. To date, none of these have been found to be a source of the bacteria.7 Usually it was isolated from the patient who had major comorbidities and recent health care exposure. If identified in blood cultures the attributable mortality rate was 18.2%.8 As far as we know, there was no report for Elizabethkingia as the pathogen of gastric abscess. An appropriate choice of antibiotics by the isolation is important to reduce the duration of antibiotic treatment and mortality.

The intramucosal gastric abscess or phlegmonous gastritis is known to be related with heavy alcoholics, immunocompromised state such as human immunodeficiency virus infection, nutrition deficiency, diabetes mellitus, chronic kidney disease, leukemia, multiple myeloma, rheumatoid arthritis, and chronic steroid use. Also, the secondary type of phlegmonous gastritis is associated with the infection of other organs, such as biliary infection or hepatic abscess.9-11 In our case, he had anorexia because of persistent vomiting and epigastric pain. Nutrition deficiency was another risk factor for poor general condition.

The protruding mass with normal-looking mucosal appearance of gastric abscess is similar to that of subepithelial tumors. CT and EUS are helpful in the diagnosis of gastric abscess. Enhanced abdominal CT shows a low-density mass with peripheral ring enhancement. A typical EUS finding is the thickening of the gastric wall with a localized hypoechoic mass, which has heterogeneously mixed echogenicity.12 EUS is superior to CT scan in measuring the contents of mass, the depth, and extent of invasion. We could notice liquified materials and air-fluid level. Even after CT and EUS, it can be confused with cancerous lesions. To avoid misdiagnosis, fine-needle aspirationis are useful and if there is any purulent fluid leakage from the lesion site, an immediate and definite diagnosis of gastric abscess can be made.13

Until recently, the recommended therapy for an intramural gastric abscess was gastrectomy in combination with antibiotics. Nowadays, in order to avoid unnecessary surgery, the alternative method of initial treatment by endoscopic approach is recommended, and it has been shown to be effective. In prior studies, for the noninvasive treatment of the gastric abscess, endoscopic or percutaneous drainage was introduced.4

According to a previous report from 1972 to 2003, there were only 17 reported cases of intramural gastric abscess.4 The 16 (89%) patients of a total of 18 presented with abdominal pain. The 11 cases (61%) were performed by surgery and four (22%) cases with endoscopic drainage, and two (11%) cases with percutaneous drainage, and one (6%) case with antibiotics. Several publications since 2003 were reviewed, and 15 reported cases were identified including our case (Table 1).3,4,13-22

Table 1 Clinical Presentation and Treatment of Intramural Gastric Abscess

Author (year)Age (yr)SexSymptom at
presentation
Diagnostic
method
TreatmentSurvival
Chen et al. (2018)1347FemaleAbdominal painCT/EUSSurgery+antibioticsYes
Chen et al. (2018)1331MaleAbdominal painCE/EUSSurgery+antibioticsNo
Jun et al. (2010)1460FemaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Odish et al. (2019)1575FemaleAbdominal painCT/EUSAntibioticsYes
Alonso et al. (2013)1655FemaleAbdominal painCTEndoscopic drainage+antibioticsYes
Ota et al. (2020)1774MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Park et al. (2021)1874MaleNauseaCTSurgeryYes
Dohi et al. (2014)1963FemaleAbdominal painCTEndoscopic drainage+catheter insertion+antibioticsYes
Cole et al (2015)2046FemaleNauseaCTEndoscopic drainage+antibioticsYes
Ergün et al. (2017)2111MaleAbdominal painCTAntibioticsYes
Kimura et al. (2019)1268FemaleAbdominal painCTEndoscopic drainage+antibioticsYes
Marcos et al. (2010)2248MaleAbdominal painCT/EUSEndoscopic drainage+catheter insertion+antibioticsYes
Kiil et al. (2001)363MaleEsophagitis bleedingEGDEndoscopic drainageYes
Choong et al. (2003)475MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Current study (2022)75MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes

CT, computed tomography; EUS, endoscopic ultrasonography; EGD, esophagogastroduodenoscopy.



The technical advances of endoscopic drainage procedure have emerged as an alternative to surgical approach these days. In our case, the abscess was treated with endoscopic aspiration and irrigation after endoscopic incision. First, the top of the mass was incised about 1.5 cm up to the submucosal layer by H-knife after saline injection. Then clear fluids flowed out from the opening. We used an endoscopic retrograde cholangiopancreatography catheter for the lavage of the submucosal abscess similar to a prior study.12 An endoscopic retrograde cholangiopancreatography catheter was introduced to the incisional opening, and aspiration of the fluid for the culture study was done. Finally, 20 mL of normal saline was used to irrigate the abscess pocket. After the procedure, markedly collapsed mass was observed and the symptoms of the patient improved immediately. In other reports, which did not perform an incision, a pigtail catheter was left in place for 1 month to allow for additional drainage of pus.12 This sequence of a sufficient incision, aspiration and irrigation without remaining pigtail catheter is a minimally invasive and inexpensive way to achieve the early treatment and safety, even a follow-up endoscopy is not mandatory.

To summarize, we report a rare case of gastric wall abscess with a rare pathogen, treated with minimally invasive endoscopic incision and drainage. Appropriately chosen antibiotics confirmed from the drained sample were also helpful. Because the endoscopic approach to gastric abscess is uncommon, we expect more reports, and sharing the experience of each treatment would be important.

No potential conflict of interest relevant to this article was reported.

Study concept and design: K.R.K. Data acquisition: K.R.K., K.N.S., A.R.C., M.J.L., Y.H.P., E.M.S., C.H.T., S.A.J. Drafting of the manuscript: K.R.K., K.N.S. Critical revision of the manuscript for important intellectual content: K.R.K., K.N.S. Administrative, technical, or material support; study supervision: K.N.S., A.R.C., M.J.L., Y.H.P., E.M.S., C.H.T., S.A.J. Approval of final manuscript: all authors.

  1. Kim SB, Oh MJ, Lee SH. Gastric subepithelial lesion complicated with abscess: case report and literature review. World J Gastroenterol 2015;21:6398-6403.
    Pubmed KoreaMed CrossRef
  2. Will U, Masri R, Bosseckert H, Knopke A, Schönlebe J, Justus J. Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment. Endoscopy 1998;30:432-435.
    Pubmed CrossRef
  3. Kiil C, Rosenberg J. Gastric intramural abscess successfully drained during gastroscopy. Gastrointest Endosc 2001;53:231-232.
    Pubmed CrossRef
  4. Choong NW, Levy MJ, Rajan E, Kolars JC. Intramural gastric abscess: case history and review. Gastrointest Endosc 2003;58:627-629.
    Pubmed CrossRef
  5. Choi MH, Kim M, Jeong SJ, et al. Risk factors for Elizabethkingia acquisition and clinical characteristics of patients, South Korea. Emerg Infect Dis 2019;25:42-51.
    Pubmed KoreaMed CrossRef
  6. Kämpfer P, Matthews H, Glaeser SP, Martin K, Lodders N, Faye I. Elizabethkingia anophelis sp. nov., isolated from the midgut of the mosquito Anopheles gambiae. Int J Syst Evol Microbiol 2011;61(Pt 11):2670-2675.
    Pubmed CrossRef
  7. Centers for Disease Control and Prevention. Elizabethkingia [Internet]. Road Atlanta: Centers for Disease Control and Prevention; c2017 [cited 2022 Jun 1].
    Available from: https://www.cdc.gov/elizabethkingia/outbreaks/index.html#casecount.
  8. Figueroa Castro CE, Johnson C, Williams M, et al. Elizabethkingia anophelis: Clinical Experience of an Academic Health System in Southeastern Wisconsin. Open Forum Infect Dis 2017;4:ofx251.
    Pubmed KoreaMed CrossRef
  9. Miller AI, Smith B, Rogers AI. Phlegmonous gastritis. Gastroenterology 1975;68:231-238.
    Pubmed KoreaMed CrossRef
  10. Ajibe H, Osawa H, Yoshizawa M, et al. Phlegmonous gastritis after endoscopic submucosal dissection for early gastric cancer. Therap Adv Gastroenterol 2008;1:91-95.
    Pubmed KoreaMed CrossRef
  11. Yakami Y, Yagyu T, Bando T. Phlegmonous gastritis: a case series. J Med Case Rep 2021;15:445.
    Pubmed KoreaMed CrossRef
  12. Kimura G, Hashimoto Y, Ikeda M. Endoscopic unroofing drainage with a needle-knife for gastric wall abscess: a rare adverse event that developed after EUS-FNA. VideoGIE 2019;4:512-513.
    Pubmed KoreaMed CrossRef
  13. Chen Y, Han Y, Du J. Diagnostic challenges in differentiating intramural gastric abscess from gastric cancer: two case reports. Medicine (Baltimore) 2018;97:e12756.
    Pubmed KoreaMed CrossRef
  14. Jun WJ, Rew JS, Cho YC, et al. Gastric wall abscess caused by a fish bone and treated with endoscopic management. Korean J Gastrointest Endosc 2010;41:98-101.
  15. Odish F, Patwardhan S, Jacob M. 2745 Intramural gastric abscess: a rare condition diagnosed and managed with endoscopic ultrasound. Am J Gastroenterol 2019;114:S1517.
    CrossRef
  16. Alonso JV, de la Fuente Carillo JJ, Gutierrez Solis MA, Vara Morate FJ, López Ruiz DJ. Gastric wall abscess presenting as thoracic pain: rare presentation of an old disease. Ann Gastroenterol 2013;26:360-362.
    Pubmed KoreaMed
  17. Ota K, Yamanoue H, Aizawa N, Suzuki N, Ota K, Takasu A. Gastric submucosal abscess caused by Edwardsiella tarda infection: a case report. BMC Gastroenterol 2020;20:299.
    Pubmed KoreaMed CrossRef
  18. Park S, You MW. Retroperitoneal abscess and retropneumoperitoneum arising from a gastric intramural abscess: a case demonstrating the gastric bare area. Korean J Intern Med 2021;36:231.
    Pubmed KoreaMed CrossRef
  19. Dohi O, Dohi M, Inoue K, Gen Y, Jo M, Tokita K. Endoscopic transgastric drainage of a gastric wall abscess after endoscopic submucosal dissection. World J Gastroenterol 2014;20:1119-1122.
    Pubmed KoreaMed CrossRef
  20. Cole W, Zagorski S. Intramural gastric abscess following laparoscopic paraesophageal hernia repair. Endoscopy 2015;47 Suppl 1 UCTN:E227-E228.
    Pubmed CrossRef
  21. Ergün E, Yildiz AE, Göllü G, et al. A rare entity in children: gastric abscess. Turk J Pediatr Dis 2017;2:141-143.
    CrossRef
  22. Marcos WC, Petrini BG, Xavier RL, Starling RM, Couto JC, Ribeiro GJ. Gastric wall abscess: an uncommon condition treated by an alternative form. Clinics (Sao Paulo) 2010;65:819-821.
    Pubmed KoreaMed CrossRef

Article

Case Report

Gut and Liver 2023; 17(6): 949-953

Published online November 15, 2023 https://doi.org/10.5009/gnl220009

Copyright © Gut and Liver.

A Case of Intramural Gastric Wall Abscess, a Rare Disease Successfully Treated with Endoscopic Incision and Drainage

Kyung Rok Kim , Ki Nam Shim , A Reum Choe , Min Jong Lee , Ye Hyun Park , Eun Mi Song , Chung Hyun Tae , Sung Ae Jung

Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea

Correspondence to:Kyung Rok Kim
ORCID https://orcid.org/0000-0003-3778-0058
E-mail dkflak80@gmail.com

Received: March 9, 2022; Revised: May 27, 2022; Accepted: June 10, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Gastric wall abscess is a rare condition characterized by a purulent inflammatory process resulting in the formation of a pocket of pus in the stomach. As the mucosa is usually intact, it requires various tools such as endoscopic ultrasonography or computed tomography for the differential diagnosis to rule out more common subepithelial tumors. Even after the diagnosis, the treatment for gastric wall abscess was previously restricted to surgical resection in combination with antibiotics. Currently, in order to avoid unnecessary surgery, the alternative method of initial treatment with an endoscopic approach is recommended. It also helps to choose appropriate antibiotics with confirmation of the pathogen by drainage. There are few reports that describe the detailed processing of the endoscopic drainage, and there is no consensus on the treatment. The pathogens that cause gastric wall abscess are usually Streptococci, Staphylococci, and Escherichia coli. There is only one case reported to be caused by Candida albicans. This is the first report of Elizabethkingia anopheles as the pathogen of the gastric wall abscess. Here, we report a case of gastric wall abscess in a 75-year-old man, safely treated by endoscopic drainage and antibiotics, confirmed by isolating the contents of the abscess.

Keywords: Abdominal abscess, Phlegmon, Suction drainage, Case reports

INTRODUCTION

Gastric wall abscess is a rare disease and difficult to diagnose. Due to the characteristics of the abscess, it is difficult to culture and the therapeutic effect of empirical antibiotics can be restricted. Until now, most gastric abscess required surgical intervention if there was no response to empirical antibiotics. However, endoscopic approach is emerging as an alternative method. Here we report a unique case of gastric wall abscess treated by endoscopic drainage and specified antibiotics by culture results. The patient provided written informed consent for the publication.

CASE REPORT

A 75-year-old man visited a primary medical clinic, presenting with epigastric pain, anorexia, and vomiting. He had a history of hepaticojejunostomy due to calculous cholecystitis. He was referred to our hospital and admitted for further evaluation of the mass found on the abdominal ultrasound. In the initial laboratory results, the white blood cell count was 10,550/mL and C-reactive protein level was elevated to 4.25 mg/dL (normal range, <0.05 mg/dL). Computed tomography (CT) of the abdomen identified about 4 cm sized low-density mass-like lesion with peripheral enhancement which invaded the gastric antral submucosa, which was compatible with abscess (Fig. 1A). A 6.4-cm-sized large mass with multiple small nodular lesions in peripheral portion compatible with abscess was detected in the left lateral segment of the liver. Later, the mass in the liver was diagnosed as intrahepatic cholangiocarcinoma by ultrasound-guided liver biopsy and positron emission tomography/CT. Treatment for gastric abscess with empirical broad-spectrum antibiotics (intravenous [IV] ceftriaxone 2 g every 24 hours) was initiated. Despite treatment, during the first 4 hospital days, his pain did not improve and fever up to 38.8°C developed. White blood cell increased to 16,480/mL and the C-reactive protein level increased to 6.66 mg/mL, but there was no growth in the blood culture. We changed antibiotics (meropenem 1 g IV every 12 hours) and performed an esophagogastroduodenoscopy with endoscopic ultrasonography (EUS). Esophagogastroduodenoscopy showed a huge subepithelial tumor (Fig. 1B) and EUS showed about 4.3×2.5 cm sized homogenous mass with mixed echo from the third layer at the anterior wall of the antrum, which filled with liquified material, and air fluid level was noted (Fig. 1C). We performed endoscopic incision and drainage immediately. After the injection of saline (Fig. 2A), about 1.5-cm-sized incision up to the submucosal layer was done by H-knife (Clear-Cut Knife H type, Finemedix Co., Ltd., Daegu, Korea) (Fig. 2B). Clear fluids gushed out from the opening (Fig. 2C). An endoscopic retrograde cholangiopancreatography catheter was introduced to the opening to the abscess pocket, and aspiration was done for the culture studies (Fig. 2D). About 20 mL of saline irrigation into the lesion was done. After the procedure, the lesion was markedly collapsed (Fig. 2E). Over the following 3 days, dramatic improvement of epigastric pain was achieved. The culture from the drained fluid detected Elizabethkingia anopheles (resistant to cefepime, ceftazidime, and meropenem; sensitive to ciprofloxacin and trimethoprim/sulbactam) and Candida albicans. We added ciprofloxacin (400 mg IV every 12 hours) and fluconazole (400 mg IV every 24 hours) during the hospital stay. Previous leukocytosis became normal at 4,810/mL and the C-reactive protein level decreased to 0.59 mg/dL. Finally, the patient restored appetite when he was discharged after 10 days after endoscopic incision and drainage. In the outpatient department, he received oral ciprofloxacin (500 mg twice a day) and proton pump inhibitor (esomeprazole 20 mg once a day) and planned surgery for the cholangiocarcinoma.

Figure 1. The radiologic and endoscopic features of case. (A) The gastric wall abscess with submucosal invasion of the antrum was seen (arrow). (B) Huge subepithelial tumor was seen at the anterior wall of the antrum. (C) Mass arising from the third layer was filled with liquified material.

Figure 2. The endoscopic procedures of the intramural gastric wall abscess. (A) The site of epinephrine and saline mixture injection. (B) The endoscopic incision was done by an H-knife, (C) clear fluids gushed out immediately. (D) Aspiration and irrigation was done by an endoscopic retrograde cholangiopancreatography catheter, and (E) the lesion was markedly collapsed.

DISCUSSION

An intramural gastric abscess is a localized form of phlegmonous gastritis.1 The most common manifestation of phlegmonous gastritis is the diffuse involvement of the gastric submucosa extending into all layers of the gastric wall. A localized form is relatively rare, accounting for 5% to 15% of all phlegmonous gastritis.2 A purulent inflammatory process results in the forming of a pocket of pus, usually in the antrum and pylorus, but it can develop in any location of the stomach.3 The submucosa of the involved lesion may be thickened, and the flattened mucosa almost looks intact, so we need to rule out subepithelial tumors such as gastrointestinal stromal tumors.4

As the pathogenesis of phlegmonous gastritis is unknown, the cause of the intramural gastric abscess is not certain. The possible causes are the direct bacterial invasion through the damaged gastric mucosa. Another source can be an infection by lymphatic or hematogenous dissemination.2 To the best of our knowledge, the most common pathogens are Streptococci, Staphylococci, and Escherichia coli.4 In this case, C. albicans and E. anopheles were cultured. C. albicans are rarely reported as the pathogen, but this is the first report of E. anopheles as the pathogen of the gastric wall abscess.

First described in 2005, Elizabethkingia (nosocomial infection Gram-negative Chryseobacterium) infections are rare. It is an emerging bacterial pathogen for nosocomial condition since 2016.5 E. anopheles was first isolated from the midgut of the Anopheles gambiae mosquito in 20116 and is the most frequently isolated Elizabethkingia species in recent clinical studies. It has natural resistance to carbapenems and a variety of potential infection sources, including healthcare products, water sources and the environment. To date, none of these have been found to be a source of the bacteria.7 Usually it was isolated from the patient who had major comorbidities and recent health care exposure. If identified in blood cultures the attributable mortality rate was 18.2%.8 As far as we know, there was no report for Elizabethkingia as the pathogen of gastric abscess. An appropriate choice of antibiotics by the isolation is important to reduce the duration of antibiotic treatment and mortality.

The intramucosal gastric abscess or phlegmonous gastritis is known to be related with heavy alcoholics, immunocompromised state such as human immunodeficiency virus infection, nutrition deficiency, diabetes mellitus, chronic kidney disease, leukemia, multiple myeloma, rheumatoid arthritis, and chronic steroid use. Also, the secondary type of phlegmonous gastritis is associated with the infection of other organs, such as biliary infection or hepatic abscess.9-11 In our case, he had anorexia because of persistent vomiting and epigastric pain. Nutrition deficiency was another risk factor for poor general condition.

The protruding mass with normal-looking mucosal appearance of gastric abscess is similar to that of subepithelial tumors. CT and EUS are helpful in the diagnosis of gastric abscess. Enhanced abdominal CT shows a low-density mass with peripheral ring enhancement. A typical EUS finding is the thickening of the gastric wall with a localized hypoechoic mass, which has heterogeneously mixed echogenicity.12 EUS is superior to CT scan in measuring the contents of mass, the depth, and extent of invasion. We could notice liquified materials and air-fluid level. Even after CT and EUS, it can be confused with cancerous lesions. To avoid misdiagnosis, fine-needle aspirationis are useful and if there is any purulent fluid leakage from the lesion site, an immediate and definite diagnosis of gastric abscess can be made.13

Until recently, the recommended therapy for an intramural gastric abscess was gastrectomy in combination with antibiotics. Nowadays, in order to avoid unnecessary surgery, the alternative method of initial treatment by endoscopic approach is recommended, and it has been shown to be effective. In prior studies, for the noninvasive treatment of the gastric abscess, endoscopic or percutaneous drainage was introduced.4

According to a previous report from 1972 to 2003, there were only 17 reported cases of intramural gastric abscess.4 The 16 (89%) patients of a total of 18 presented with abdominal pain. The 11 cases (61%) were performed by surgery and four (22%) cases with endoscopic drainage, and two (11%) cases with percutaneous drainage, and one (6%) case with antibiotics. Several publications since 2003 were reviewed, and 15 reported cases were identified including our case (Table 1).3,4,13-22

Table 1 . Clinical Presentation and Treatment of Intramural Gastric Abscess.

Author (year)Age (yr)SexSymptom at
presentation
Diagnostic
method
TreatmentSurvival
Chen et al. (2018)1347FemaleAbdominal painCT/EUSSurgery+antibioticsYes
Chen et al. (2018)1331MaleAbdominal painCE/EUSSurgery+antibioticsNo
Jun et al. (2010)1460FemaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Odish et al. (2019)1575FemaleAbdominal painCT/EUSAntibioticsYes
Alonso et al. (2013)1655FemaleAbdominal painCTEndoscopic drainage+antibioticsYes
Ota et al. (2020)1774MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Park et al. (2021)1874MaleNauseaCTSurgeryYes
Dohi et al. (2014)1963FemaleAbdominal painCTEndoscopic drainage+catheter insertion+antibioticsYes
Cole et al (2015)2046FemaleNauseaCTEndoscopic drainage+antibioticsYes
Ergün et al. (2017)2111MaleAbdominal painCTAntibioticsYes
Kimura et al. (2019)1268FemaleAbdominal painCTEndoscopic drainage+antibioticsYes
Marcos et al. (2010)2248MaleAbdominal painCT/EUSEndoscopic drainage+catheter insertion+antibioticsYes
Kiil et al. (2001)363MaleEsophagitis bleedingEGDEndoscopic drainageYes
Choong et al. (2003)475MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Current study (2022)75MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes

CT, computed tomography; EUS, endoscopic ultrasonography; EGD, esophagogastroduodenoscopy..



The technical advances of endoscopic drainage procedure have emerged as an alternative to surgical approach these days. In our case, the abscess was treated with endoscopic aspiration and irrigation after endoscopic incision. First, the top of the mass was incised about 1.5 cm up to the submucosal layer by H-knife after saline injection. Then clear fluids flowed out from the opening. We used an endoscopic retrograde cholangiopancreatography catheter for the lavage of the submucosal abscess similar to a prior study.12 An endoscopic retrograde cholangiopancreatography catheter was introduced to the incisional opening, and aspiration of the fluid for the culture study was done. Finally, 20 mL of normal saline was used to irrigate the abscess pocket. After the procedure, markedly collapsed mass was observed and the symptoms of the patient improved immediately. In other reports, which did not perform an incision, a pigtail catheter was left in place for 1 month to allow for additional drainage of pus.12 This sequence of a sufficient incision, aspiration and irrigation without remaining pigtail catheter is a minimally invasive and inexpensive way to achieve the early treatment and safety, even a follow-up endoscopy is not mandatory.

To summarize, we report a rare case of gastric wall abscess with a rare pathogen, treated with minimally invasive endoscopic incision and drainage. Appropriately chosen antibiotics confirmed from the drained sample were also helpful. Because the endoscopic approach to gastric abscess is uncommon, we expect more reports, and sharing the experience of each treatment would be important.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Study concept and design: K.R.K. Data acquisition: K.R.K., K.N.S., A.R.C., M.J.L., Y.H.P., E.M.S., C.H.T., S.A.J. Drafting of the manuscript: K.R.K., K.N.S. Critical revision of the manuscript for important intellectual content: K.R.K., K.N.S. Administrative, technical, or material support; study supervision: K.N.S., A.R.C., M.J.L., Y.H.P., E.M.S., C.H.T., S.A.J. Approval of final manuscript: all authors.

Fig 1.

Figure 1.The radiologic and endoscopic features of case. (A) The gastric wall abscess with submucosal invasion of the antrum was seen (arrow). (B) Huge subepithelial tumor was seen at the anterior wall of the antrum. (C) Mass arising from the third layer was filled with liquified material.
Gut and Liver 2023; 17: 949-953https://doi.org/10.5009/gnl220009

Fig 2.

Figure 2.The endoscopic procedures of the intramural gastric wall abscess. (A) The site of epinephrine and saline mixture injection. (B) The endoscopic incision was done by an H-knife, (C) clear fluids gushed out immediately. (D) Aspiration and irrigation was done by an endoscopic retrograde cholangiopancreatography catheter, and (E) the lesion was markedly collapsed.
Gut and Liver 2023; 17: 949-953https://doi.org/10.5009/gnl220009

Table 1 Clinical Presentation and Treatment of Intramural Gastric Abscess

Author (year)Age (yr)SexSymptom at
presentation
Diagnostic
method
TreatmentSurvival
Chen et al. (2018)1347FemaleAbdominal painCT/EUSSurgery+antibioticsYes
Chen et al. (2018)1331MaleAbdominal painCE/EUSSurgery+antibioticsNo
Jun et al. (2010)1460FemaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Odish et al. (2019)1575FemaleAbdominal painCT/EUSAntibioticsYes
Alonso et al. (2013)1655FemaleAbdominal painCTEndoscopic drainage+antibioticsYes
Ota et al. (2020)1774MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Park et al. (2021)1874MaleNauseaCTSurgeryYes
Dohi et al. (2014)1963FemaleAbdominal painCTEndoscopic drainage+catheter insertion+antibioticsYes
Cole et al (2015)2046FemaleNauseaCTEndoscopic drainage+antibioticsYes
Ergün et al. (2017)2111MaleAbdominal painCTAntibioticsYes
Kimura et al. (2019)1268FemaleAbdominal painCTEndoscopic drainage+antibioticsYes
Marcos et al. (2010)2248MaleAbdominal painCT/EUSEndoscopic drainage+catheter insertion+antibioticsYes
Kiil et al. (2001)363MaleEsophagitis bleedingEGDEndoscopic drainageYes
Choong et al. (2003)475MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes
Current study (2022)75MaleAbdominal painCT/EUSEndoscopic drainage+antibioticsYes

CT, computed tomography; EUS, endoscopic ultrasonography; EGD, esophagogastroduodenoscopy.


References

  1. Kim SB, Oh MJ, Lee SH. Gastric subepithelial lesion complicated with abscess: case report and literature review. World J Gastroenterol 2015;21:6398-6403.
    Pubmed KoreaMed CrossRef
  2. Will U, Masri R, Bosseckert H, Knopke A, Schönlebe J, Justus J. Gastric wall abscess, a rare endosonographic differential diagnosis of intramural tumors: successful endoscopic treatment. Endoscopy 1998;30:432-435.
    Pubmed CrossRef
  3. Kiil C, Rosenberg J. Gastric intramural abscess successfully drained during gastroscopy. Gastrointest Endosc 2001;53:231-232.
    Pubmed CrossRef
  4. Choong NW, Levy MJ, Rajan E, Kolars JC. Intramural gastric abscess: case history and review. Gastrointest Endosc 2003;58:627-629.
    Pubmed CrossRef
  5. Choi MH, Kim M, Jeong SJ, et al. Risk factors for Elizabethkingia acquisition and clinical characteristics of patients, South Korea. Emerg Infect Dis 2019;25:42-51.
    Pubmed KoreaMed CrossRef
  6. Kämpfer P, Matthews H, Glaeser SP, Martin K, Lodders N, Faye I. Elizabethkingia anophelis sp. nov., isolated from the midgut of the mosquito Anopheles gambiae. Int J Syst Evol Microbiol 2011;61(Pt 11):2670-2675.
    Pubmed CrossRef
  7. Centers for Disease Control and Prevention. Elizabethkingia [Internet]. Road Atlanta: Centers for Disease Control and Prevention; c2017 [cited 2022 Jun 1]. Available from: https://www.cdc.gov/elizabethkingia/outbreaks/index.html#casecount.
  8. Figueroa Castro CE, Johnson C, Williams M, et al. Elizabethkingia anophelis: Clinical Experience of an Academic Health System in Southeastern Wisconsin. Open Forum Infect Dis 2017;4:ofx251.
    Pubmed KoreaMed CrossRef
  9. Miller AI, Smith B, Rogers AI. Phlegmonous gastritis. Gastroenterology 1975;68:231-238.
    Pubmed KoreaMed CrossRef
  10. Ajibe H, Osawa H, Yoshizawa M, et al. Phlegmonous gastritis after endoscopic submucosal dissection for early gastric cancer. Therap Adv Gastroenterol 2008;1:91-95.
    Pubmed KoreaMed CrossRef
  11. Yakami Y, Yagyu T, Bando T. Phlegmonous gastritis: a case series. J Med Case Rep 2021;15:445.
    Pubmed KoreaMed CrossRef
  12. Kimura G, Hashimoto Y, Ikeda M. Endoscopic unroofing drainage with a needle-knife for gastric wall abscess: a rare adverse event that developed after EUS-FNA. VideoGIE 2019;4:512-513.
    Pubmed KoreaMed CrossRef
  13. Chen Y, Han Y, Du J. Diagnostic challenges in differentiating intramural gastric abscess from gastric cancer: two case reports. Medicine (Baltimore) 2018;97:e12756.
    Pubmed KoreaMed CrossRef
  14. Jun WJ, Rew JS, Cho YC, et al. Gastric wall abscess caused by a fish bone and treated with endoscopic management. Korean J Gastrointest Endosc 2010;41:98-101.
  15. Odish F, Patwardhan S, Jacob M. 2745 Intramural gastric abscess: a rare condition diagnosed and managed with endoscopic ultrasound. Am J Gastroenterol 2019;114:S1517.
    CrossRef
  16. Alonso JV, de la Fuente Carillo JJ, Gutierrez Solis MA, Vara Morate FJ, López Ruiz DJ. Gastric wall abscess presenting as thoracic pain: rare presentation of an old disease. Ann Gastroenterol 2013;26:360-362.
    Pubmed KoreaMed
  17. Ota K, Yamanoue H, Aizawa N, Suzuki N, Ota K, Takasu A. Gastric submucosal abscess caused by Edwardsiella tarda infection: a case report. BMC Gastroenterol 2020;20:299.
    Pubmed KoreaMed CrossRef
  18. Park S, You MW. Retroperitoneal abscess and retropneumoperitoneum arising from a gastric intramural abscess: a case demonstrating the gastric bare area. Korean J Intern Med 2021;36:231.
    Pubmed KoreaMed CrossRef
  19. Dohi O, Dohi M, Inoue K, Gen Y, Jo M, Tokita K. Endoscopic transgastric drainage of a gastric wall abscess after endoscopic submucosal dissection. World J Gastroenterol 2014;20:1119-1122.
    Pubmed KoreaMed CrossRef
  20. Cole W, Zagorski S. Intramural gastric abscess following laparoscopic paraesophageal hernia repair. Endoscopy 2015;47 Suppl 1 UCTN:E227-E228.
    Pubmed CrossRef
  21. Ergün E, Yildiz AE, Göllü G, et al. A rare entity in children: gastric abscess. Turk J Pediatr Dis 2017;2:141-143.
    CrossRef
  22. Marcos WC, Petrini BG, Xavier RL, Starling RM, Couto JC, Ribeiro GJ. Gastric wall abscess: an uncommon condition treated by an alternative form. Clinics (Sao Paulo) 2010;65:819-821.
    Pubmed KoreaMed CrossRef
Gut and Liver

Vol.18 No.4
July, 2024

pISSN 1976-2283
eISSN 2005-1212

qrcode
qrcode

Share this article on :

  • line

Popular Keywords

Gut and LiverQR code Download
qr-code

Editorial Office