Phlegmonous gastritis: A rare entity as a differential diagnostic of an acute abdomen. Description of a case and a bibliographic review

10_NC_3295_Rada.ing.inddCLINICAL NOTE
Phlegmonous gastritis: A rare entity as a differential diagnostic of an acute abdomen. Description of a case and a bibliographic review
Arantzazu Rada-Palomino1, Arantxa Muñoz-Duyos1, Noelia Pérez-Romero1, Harold Vargas-Pierola1, Noelia Puértolas-Rico1, Laura Ruiz-Campos2, Jorge Espinós-Pérez1 and Enrique Veloso-Veloso1
Departments of 1General Surgery and 2Digestive. Hospital Universitario Mútua Terrassa. Barcelona, Spain
1130-0108/2014/106/6/418-424 Revista española de enfeRmedades digestivas CopyRight © 2014 aRán ediCiones, s. l.
Rev esp enfeRm dig (Madrid Vol. 106, N.º 6, pp. 418-424, 2014
CLINICAL NOTE
ABSTRACT
Phlegmonous gastritis is a rare bacterial infection of the gastric wall, which progress rapidly. It is characterized by a purulent inflammation that can affect the entire gastrointestinal tract and presents a high mortality rate. We are reporting a case of phlegmonous gastritis in an HIV-seropositive man successfully treated with antibiotics. Moreover, a review of the English and Spanish literature is carried out, from 1980 to the present time. The most frequently involved microorganism is Streptococcus spp. (57 %), but the polimicrobial infection is also frequent (17 %). The most important symptom is the intensive epigastric pain associated with vomits and most cases were diagnosed by CT and/ or fibrogastroscopy. There are many existing risk factors described. The main one is the immunesuppression, although in 40 % of the cases no risk factors were identified. The global mortality is 27 % without identifying significant differences between antibiotics and surgical treatment, for that reason it is recommended to initiate antibiotic treatment right from the beginning and postponing surgery for the refractory cases and complications.
Key words: Phlegmonous gastritis. Streptococcus A infection.
INTRODUCTION
Phlegmonous gastritis is a rare entity which has a high mortality rate in spite of being treated from an early stage. It consists of a bacterial infection of the gastric wall, local or disseminated, which can produce a purulent discharge. It is caused mainly by Streptococcus spp., although many other microorganisms have been found. The main risk fac- tor is the immunosuppression or the record of any inva- sive procedure, but many patients do not present known risk factors (1-3). We are reporting an isolated case that occurred in our hospital and a review of the English and Spanish literature is carried out from 1980.
CASE REPORT
A 62-year-old male consulted our Emergency Depart- ment because of a sudden intense epigastric pain, with a three hours evolution and that had initiated 3 days before and was associated with aqueous diarrhea, vomits and an episode of hematemesis. As an isolated clinical anteced- ent the patient was HIV-seropositive, he was following an antiretroviral therapy and the last measurement of CD4 was 340-450 cell/mL with an undetectable viral charge.
When the patient arrived at the emergency department, he presented a general deterioration, pallor mucocutane- ous and profuse sweating. His vital functions were stable (blood pressure 100/60 mmHg, heart rate 85 bpm) and his body temperature was 37.4 °C. His abdomen was soft but painful under epigastric pressure and showed signs of peri- toneal irritation at this level. The blood test showed acute renal failure (creatinine 4.1 mg/dL), leukocytosis with neu- trophilic left shift (leukocytes, 6.20 x 109/L, 71 % neu- trophils and 18 % bands), C-reative protein, 362.4 mg/L, procalcitonin, 33 mg/mL and metabolic acidosis (pH, 7.20; pCO
2 : 41 mm Hg; HCO
3 , 16 mmol/L; EB -12 mmol/L).
The ECG and the abdominal and thoracic X-rays did not
Received: 22-01-2014 Accepted: 28-02-2014
Correspondence: Arantzazu Rada Palomino. Department of General Surgery. Hospital Universitario Mutua Terrassa. Plaza del Doctor Robert, 5. 08221 Terrasa, Barcelona. Spain e-mail: [email protected]
Rada-Palomino A, Muñoz-Duyos A, Pérez-Romero N, Vargas- Pierola H, Puértolas-Rico N, Ruiz-Campos L, Espinós-Pérez J, Veloso-Veloso E. Phlegmonous gastritis: A rare entity as a differ- ential diagnostic of an acute abdomen. Description of a case and a bibliographic review. Rev Esp Enferm Dig 2014;106:418-424.
Vol. 106, N.º 6, 2014 PHLEGMONOUS GASTRITIS: A RARE ENTITY AS A DIFFERENTIAL DIAGNOSTIC OF AN ACUTE ABDOMEN. 419 DESCRIPTION OF A CASE AND A BIBLIOGRAPHIC REVIEW
Rev esp enfeRm Dig 2014; 106 (6): 418-424
show any alterations. During his stay in the emergency department, the patient evolved quickly to a hemodynamic instability, developing a septic shock, needing to begin resuscitation measures and empirical antibiotic treatment with cefotaxime and metronidazole.
An abdominal CT was performed that showed a dif- fuse thickening of the gastric wall and the antral region with changes in the density of the fat covering the greater
curvature, little free liquid and absence of pneumoperito- neum (Fig. 1). With these findings, a fibrogastroscopy was carried out, which showed increased, edematous and ery- thematous gastric folds, findings compatible with phleg- monous gastritis (Fig. 2), furthermore an esophagitis with Los Angeles grade C.
Due to the initial hemodynamic instability and the acute renal failure with oliguria, the patient was admitted into the
Fig. 1. Diffuse thickening of the gastric wall and the antral region, with involvement of the adjacent fat and minimal amount of free fluid. No presence of extraluminal air.
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intensive care unit, needing support with vasoactive drugs during the first 24 hours, invasive mechanical ventilation, hemodiafiltration and parenteral nutrition.
The histological study of the gastric biopsies showed an acute inflammation with abscesses in the submucosa, which confirmed the diagnosis of the phlegmonous gastri- tis (Fig. 3). The culture of the biopsies and the hemoculture were positive for Streptococcus pyogenes. Therefore, the antibiotic treatment was modified to penicillin G and clin- damycin according to antibiogram.
As a secondary complication to the resuscitation mea- sures, the patient developed an acute pulmonary edema and pneumonia. The subsequent evolution was favorable and the patient was discharged after 28 days in hospital with no new abdominal symptoms.
DISCUSSION
Phlegmonous gastritis is a rare entity mentioned for the first time in 1862 by Cruveilhier (2) and, since then, about 500 cases have been published. We have carried out a bibliographic search using the data base Pubmed, with the key words “Phlegmonous gastritis” and “Supurative gas- tritis”. From 1980 to 2013, 45 cases have been reported in the English and Spanish literature, which are summarized in Table I. A bivariant analysis was performed comparing the mortality rate according to the presence of the risk fac- tors and the treatment applied. For the bivariant analysis, the statistical program Stat View 4.0. was used, using the exact Fisher test to the qualitative variants, considering a value of p < 0.05 as significant.
This pathology consists of a purulent inflammation of the gastric wall caused by a bacterial infection. The main pathogen is Streptococcus spp. (especially S. pyogenes) isolated in about 70 % of cases. However, a lot of other microorganisms have been identified as etiologic agents: Staphylococcus spp., Escherichia coli, Haemophilus influ-
enzae, Proteus and Clostridium spp. (3-6). In this review, the pathogen was identified in 67 % of the cases (30/45). Streptococcus spp. was isolated in 57 %. We can also high- light the percentage of cases of polymicrobial infection, 17 % (Table II).
The symptoms of phlegmonous gastritis usually set in 24 hours, although they can develop during several days. They include abdominal pain, which can be very intense and usually located in the epigastric region, nauseas, vomits, fever with or without feverish chill, diarrheas and hematemesis (4-7). All these are very unspecific signs and symptoms, and for this reason a high index of suspicion is required for the diagnosis of this entity, which must be considered in the differential diagnostic of the acute abdomen. Some authors describe the purulent vomits as pathognomonic, although these did not appear in any of the 45 reviewed cases.
About half of the patients affected by phlegmonous gastritis have immunosuppressor factors such as alco- holism, diabetes mellitus, HIV, chronic hepatitis B or treatment with corticoids. The phlegmonous gastritis has also been described as a very rare complication after gastric biopsies or any other invasive procedure. It is believed that these factors predispose the gastric infec- tion eliminating several mechanisms of defense. How- ever, the exact pathogenesis of phlegmonous gastritis is unknown and predisposing factors are identified in 60 % of the reviewed cases, being the mortality rate of this group of 33 %. No risk factors were identified in 40 % of the cases and the mortality rate of this group was 17 % (NS). Among the risk factors identified in the review are included alcoholism, HIV, BHV, diabetes mellitus, neo- plasms, immunosuppressive treatment, gastric biopsies, esophagectomy and other invasive procedures, gastric or in other locations, performed in the previous weeks to the initiation of the symptoms.
The histology of this entity shows an acute inflamma- tion of gastric submucosa. Furthermore, the culture of the
Fig. 3. Acute inflammation with abscesses in the submucosa. Asterisks indicate neutrophilic abscesses in the submucosa.
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Table I. Summary of clinical data of cases of phlegmonous gastritis reported between 1980 and 2013
Author Year Age Sex Risk factors Diagnosis Microorganism Treatment Result
Nicholson BW (16) 1980 78 F No Intraoperatory S. epidermidis + E. aerogenes
Gastric drainage Death
Chen ST (17) 1980 54 M No Intraoperatory Streptococcus spp. Partial gastrectomy
Death
Lifton LJ (9) 1982 70 M No Intraoperatory Streptococcus group C Drainage + Gastrostomy
Discharge
Cowan SS (18) 1983 80 F No Autopsy ? No Death
Horning D (19) 1983 60 F Endoscopic resection for gastric cancer
Intraoperatory ? Gastrectomy Discharge
Blei ED (20) 1983 38 F IDU + cirrhosis Autopsy S. pneumoniae No Death
Mittleman RE (21) 1985 29 M HIV + milliary TB
Intraoperatory S. pyogenes No Death
Bracco E (22) 1987 51 M DM + alcoholism
TC + FGS ? ATB Death
Tierney LM (4) 1987 63 M Alcoholism TC H. influenzae ATB Death
O'Toole (2) 1988 30 M DM + alcoholism
Autopsy S. pyogenes No Death
Avilés JF (13) 1988 59 F Disseminated rectal carcinoma
Intraoperatory S. pyogenes Surgical drainage + ATB
Discharge
Cruz FO (23) 1992 78 F No TC E. coli + P. mirabelis Gastrectomy Discharge
Zazzo JC (10) 1992 40 M Alcoholism + HIV
Intraoperatory S. pyogenes ATB Discharge
Van Leeuwen ML (24)
1993 28 F No FGS - ATB + Corticoids for Sjögren syndrome
Discharge
Ross DA (8) 1994 44 F Corticoids TC ? Gastrectomy Discharge
Wakayama T (25) 1994 31 M No TC E. cloacae + K. pneumoniae Esofagectomy and gastrectomy
Discharge
Intraoperatory K. pneumoniae Esofagectomy and gastrectomy
Discharge with gastric sequelae
S. pyogenes ATB Discharge
Radhi J (27) 1999 75 M Coronay bypass 3 days before
Autopsy ? No Death
Jaballah S (28) 1999 23 M No Ecography ? Gastrectomy Discharge
Jaballah S (28) 1999 40 M Alcoholism Ecography ? Gastrectomy Discharge
Iwakiri Y (29) 1999 32 F No FGS S. pneumoniae ATB Discharge
Joko T (30) 1999 54 F Corticoids Autopsia ? No Death
HU DC (31) 2000 35 F No US + CT + FGS - ATB Discharge
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Table I (Cont.). Summary of clinical data of cases of phlegmonous gastritis reported between 1980 and 2013
Author Year Age Sex Risk factors Diagnosis Microorganism Treatment Result
Cohen ME (32) 2000 32 F No EUS S. pneumoniae ATB Discharge
Staroverov VV (11) 2001 44 F No US ? Surgical drainage
Discharge
CT S. pyogenes Partial gastrectomy
Discharge
Lee BS (34) 2005 68 F Endoscopic resection for gastric cancer
CT + FGS Enterococcus fecalis Gastrectomy Discharge
Kim GY (3) 2005 44 M No CT + FGS Enterococcus faecium ATB Discharge
Kim GY (3) 2005 60 F DM + cirrhosis CT + FGS Clostrium seticum ATB Death
Harikumar R (35) 2007 70 F Gastric lymphoma UD + CT + FGS S. pyogenes ATB Death
Hommel S (36) 2007 32 F No Intraoperative S. pyogenes ATB Discharge
Corti M (37) 2007 36 M Alcoholism + HIV Intraoperative ? ATB Discharge
Ajibe H (38) 2008 74 F DM + Endoscopic resection for gastric cancer
CT + FGS Citrobacter freundii, Enterobacter cloacae y Streptococcus spp.
ATB and total gastrectomy at 10 days
Discharge
CT + FGS Enterococcus spp. ATB Discharge
Rajendran S (40) 2009 65 F No CT + FGS ? ATB Discharge
Park CW (42) 2010 73 F No CT + FGS E. coli, Acinetobacter calcoacet
Surgery and ATB
Discharge
Kim HS (6) 2010 48 M DM + Alcoholism CT + FGS K. pneumoniae Thoracotomy + Surgical drainage
Discharge
Guisado P (5) 2010 50 M DM US + CT + FGS ? ATB Discharge
Paik DC (42) 2010 45 M Sinus surgery Intraoperative S. pyogenes ATB Discharge
Munroe CA (43) 2010 58 M HBV CT + FGS + EUS
Streptococcus spp. ATB Discharge
Itonaga M (44) 2012 70 F EUS-FNA of pancreatic TM
CT + FGS Streptococcus spp. ATB Discharge
Fan JQ (45) 2013 65 M Splenectomy + esofagectomy in previous days
CT + FGS S. aureus ATB Discharge
Liu YJ (46) 2013 84 M No CT + FGS ? Gastrectomy Discharge
Rada A (actual case) 2013 62 M HIV CT + FGS S. pyogenes ATB Discharge
M: Male; F: Female; TB: Tuberculosis; HIV: HIV-seopositive; FGS: Fibrogastroscope; US: Ultrasonography; TC: Abdominal computed tomography; FNA: Fine-needle aspira- tion; EUS: Endoscopic ultrasound; IDU: Intravenous drug user; DM: Diabetes mellitus; HBV: Hepatitis B; ATB: Antibiotics.
biopsies permits the isolation of the responsible pathogen and all this makes the differential diagnostic with other entities such as the gastric carcinoma, the MALT lympho- ma, the GIST, the leiomyoma or the carcinoid tumor (5). However, imaging tests such as abdominal ultrasonog- raphy or CT, which reveal thickening of the gastric wall with involvement of the adjacent fat (11,13), as well as the fibrogastroscope, which shows the presence of edematous
and erythematosus gastric folds with fibrinopurulent dis- charge. These finding offer us a highly suspicious diagno- sis allowing us to initiate the treatment as soon as possible, with the aim of improving the possibilities of survival of the patients.
In the first reported cases, the diagnosis was mostly sur- gical and, consequently, the treatment was mostly surgical drainage with or without gastric resection. From the 80s
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onwards, coinciding with the development of the CT, the phlegmonous gastritis was being diagnosed sooner and parenteral antibiotics was becoming more common as the single treatment. Out of 45 reviewed cases, 47 % were treated only with parenteral antibiotics and 40 % needed surgical treatment with or without gastric resection; the remaining 13 % were diagnosed during the autopsy and for this reason we have no information about the treatment the received.
In 1919, Sundberg reported a series of 215 cases and the mortality rate was 92 % (14). In posterior publications, the mortality rate has been reducing gradually with the devel- opment of antibiotics and the earlier diagnosis (3,14,15). The mortality rate of the 45 reviewed cases of our report was 27 % (12/45). In the group treated with antibiotics, 80 % was discharged from the hospital without any abdom- inal symptoms and the mortality rate was 19 % and, in the group treated with surgery, 6 % present gastrointestinal after-effects and the mortality rate was 11 %. The bivari- ant analysis did not identify significant differences in the morbi-mortality between surgical and antibiotic treatment, for which reason it is recommended to initiate antibiotic treatment right from the beginning and postpone surgery from the refractory cases and the complications and so avoid gastric resections.
In conclusion, phlegmonous gastritis is a rare entity which has to be considered in the differential diagnosis of the acute abdomen, especially in patients with any predis- posing factor and who require a high index of suspicion. The ultrasonography, the abdominal CT and the endo- scope are very useful for the initial diagnosis, although the definitive diagnosis will be given by the histology and the culture of the gastric biopsies. The most frequent isolat- ed microorganism is Streptococcus spp. but polymicrobial infection is also frequent. In spite of the reduced mortality rate, this is still 27 %, for which reason it is fundamen- tal to initiate antibiotic treatment as soon as possible and consider surgery in refractory cases and in the presence of complications.
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