A53 DIFFUSE PHLEGMONOUS GASTRITIS. (1st March 2018)

• Record Type: Journal Article
• Authors: Aruljothy, A; Camilleri-Broet, S; Mayrand, S; Ferri, L; Bessissow, T
• Is Part Of: Journal of the Canadian Association of Gastroenterology. Volume 1(2018)Supplement 2
• Page Start: 85
• Page End: 86
• Publication Date: 2018-03-01
• Subjects: Gastroenterology -- Periodicals; 616.33005
• DOI: 10.1093/jcag/gwy009.053
• Languages: English
• ISSNs: 2515-2084

Abstract

Abstract: Background: Phlegmonous gastritis is a rare inflammatory disease of the stomach caused by suppurative exudate, associated with a high mortality rate with treatment delay. Thus, strong clinical suspicion and recognition of this disease is key to the diagnosis and prompt management. Aims: Describe a case of diffuse phlegmonous gastritis presenting as ischemic gastritis and shock. Methods: Case report Results: A 78 year-old Haitian male with hypertension, dyslipidemia, and a coronary artery bypass grafting presented to the emergency room (ER) with epigastric pain and diarrhea. His temperature was 37.1, with a blood pressure 76/45, heart rate 108, distended abdomen, epigastric tenderness without peritoneal signs, leukocytosis of 18.3 x 10 9 /L, CRP 15.8 mg/L, and lactate 8.8 mmol/L. A computed tomography (CT) showed a distended stomach with circumferential wall thickening, and gastrohepatic ligament fat stranding. Gastroscopy showed a diffuse friable, dusky gastric mucosa with multiple ulcerations, and spontaneous bleeding suspicious for ischemic gastritis versus malignancy. Biopsy showed necrotic tissue and no malignancy. In the ICU, he improved with intravenous fluids, 5 days of Piperacillin and Tazobactam, pantoprazole, and was investigated for vasculitis which was negative. A CT angiogram showed patent abdominal arteries. Repeat endoscopy showed patchy healing of the antrum and body with necrotic areas at the fundus. Biopsy showed increased eosinophils suggestive of eosinophilic gastritis, and no H. pylori. He improved on conservative management and was discharged with pantoprazole BID but returned to the ER 10 days later with dysphagia, vomiting, and a 50lbs weight loss. Gastroscopy showed a stomach with diffuse nodularity, pus, and remaining large antral ulcerations. Biopsy revealed gastric mucosa with eosinophils. Infectious Diseases was consulted and excluded latent TB and parasitic infection (no peripheral eosinophilia, negative Strongyloides and stool cultures). He was discharged on prednisone for presumed eosinophilic gastritis but his symptoms and endoscopy did not improve, prednisone was stopped after a 2 month taper. On 1 month follow-up, gastroscopy showed persistent diffuse nodular, friable gastric mucosa, and a large antral ulcer. Biopsy showed no eosinophilic gastritis, but evidence of H. pylori. He was rehospitalized for malnutrition and symptom control with a working diagnosis of phlegmonous gastritis in the healing phase and remained on pantoprazole BID. He was discharged with 14-days of H. pylori eradication therapy and was seen in 5 weeks with symptom resolution. Repeat endoscopy showed healed mucosa with diffuse scarring and histology confirmed no H. pylori and healed mucosa. Conclusions: Phlegmonous gastritis may present with shock and ischemic-like endoscopic features and requires prompt recognition and treatment with broad-spectrum antibiotics and conservative management. Funding Agencies: None