A 63-year-old man with no surgical history, taking no medication,was referred to the emergency department for epigastric pain and nausea that had started afew hours earlier. A sore throat had begun 24hours previously.
Physical examination revealed normal temperature, hemodynamic stability, a distended abdomen with abdominal guarding that was very painful on palpation, and no mass or cutaneous lesions. Labs showed 14,450 leukocytes/mm3 (91% neutrophils) and C-reactive protein 82.3 mg/L; electrocardiogram and chest and abdominal X-rays were normal.
Due to persistent pain, the patient underwent abdominal computed tomography (CT) with contrast, which showed free liquid, diffuse thickening of the gastric wall, and changes in density of the fat surrounding the greater curvature, without pneumoperitoneum (Figures 1 and 2). The urgent upper gastrointestinal endoscopy performed showed edematous and erythematous gastric mucosa.
Despite imipenem, fluid therapy, analgesics, and nil by mouth, progress was not satisfactory. The patient had hypotension and tachycardia, and blood tests showed leukopenia (2,170 leukocytes/mm3, 79% neutrophils), coagulopathy (INR 1.88), C-reactive protein 439.8mg/L, and procalcitonin 29.2ng/ml. With signs of sepsis, a further abdominal CT showed no difference from the previous one.
Urgent surgical procedure evidenced purulent ascites and gastric necrosis, and a full gastrectomy with Roux-en-Y reconstruction was performed (Figures 3 and 4).
Histology showed edema and acute inflammation of the gastric wall with a histiocytic reaction and presence of bacterial colonies (Figure5). Ascetic fluid culture was positive for Streptococcus pyogenes.
The patient remained on the intensive care unit for 2days, subsequently tolerating a progressive diet and completing a cycle of antibiotics with good clinical progress.
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-Estela Soria López, MD, Ana Villar Puertas, MD, Yolanda María Sánchez Rodríguez, MD, Francisco Granados Pacheco, MD, José Miguel Rosales Zábal, MD, Fátima Fernández Gutiérrez del Álamo, MD, Teresa Pereda Salguero, MD, Francisco Martín Carvajal, MD, Julio Bercedo Martínez, MD
This article originally appeared in the August issue of The American Journal of Medicine.
