P3381 - Phlegmonous Gastritis Due to Presumed Helicobacter pylori Infection

Sangini Tolia, MD¹, Marjan Haider, MD¹, Sarvani Surapaneni, MD¹, Kevin Platt, MD², Emily Tommolino, MD^2
1Trinity Health Ann Arbor Hospital, Ann Arbor, MI; ²Huron Gastroenterology, Ann Arbor, MI

Introduction: Phlegmonous or purulent gastritis (PG) is a rare infection of the gastric wall. Patients may present with nonspecific symptoms and can develop rapid systemic progression with high mortality. Here, we present a case of acute PG that initially did not respond to antibiotic therapy and was empirically treated with quadruple therapy for presumed Helicobacter pylori infection. The patient recovered and did not need surgery.

Case Description/Methods: A 59-year-old female presented to the hospital with two days of intractable nausea, vomiting, epigastric pain, and inability to tolerate oral intake. She endorsed chronic constipation, and denied diarrhea, fever, chills, sick contacts, and had not eaten any unusual foods. She had no pertinent medical or family history. Home medications included a daily proton-pump inhibitor (PPI). Her leukocyte count was 20.2 × 109/L (normal 4-10). Abdominal computed tomography (CT) was notable for diffuse gastric wall thickening. An upper gastrointestinal endoscopy (EGD) showed severe, unusual appearing mucosa with antral sparing. Biopsy revealed diffuse acute purulent gastritis with surface ulceration and erosion, crypt abscesses and pockets of neutrophils. It was negative for Helicobacter pylori, fungal organisms, virocytes, and malignancy. She was initially treated with ceftriaxone and twice daily intravenous proton-pump inhibitor. However, due to persistent symptoms and leukocytosis, a second EGD was performed, showing persistent acute gastritis with intense erythema and exudates in the gastric fundus and body, with an abrupt transition to normal-appearing mucosa in the antrum. She was taking a PPI prior to the biopsy, so we considered the possibility of a false negative H. pylori result. She was then empirically started on quadruple therapy (clarithromycin, metronidazole, amoxicillin, and PPI) for 14 days to treat H. pylori. At her follow-up appointment, her symptoms and leukocytosis had improved. She was scheduled for a repeat outpatient EGD to ensure endoscopic resolution.

Discussion: PG is a rare diagnosis characterized by pus and inflammation of the gastric submucosa. The most common causative pathogens are Streptococci, and antibiotics are the initial treatment of choice. In our case, no infection was isolated from the biopsies, but she improved after starting empiric treatment for H. pylori. PG carries a high mortality of up to 84%, so it is crucial to identify the diagnosis and treat promptly. If medical therapy fails, surgical intervention may be required.



Disclosures:


Sangini Tolia, MD¹, Marjan Haider, MD¹, Sarvani Surapaneni, MD¹, Kevin Platt, MD², Emily Tommolino, MD². P3381 - Phlegmonous Gastritis Due to Presumed <i>Helicobacter pylori</i> Infection, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.