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Phlegmonous gastritis: a case series

• Yoshikazu Yakami 1 ,
• Toshihiko Yagyu 1 &
• Tomoki Bando 1  

Journal of Medical Case Reports volume  15 , Article number:  445 ( 2021 ) Cite this article

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Phlegmonous gastritis is a rare and fatal infectious disease of the stomach, presenting varied and nonspecific endoscopic images, which are therefore difficult to diagnose. This report discusses three cases of phlegmonous gastritis, each with unique endoscopic images, and considers the differential diagnosis of this disease. These cases were initially suspected of scirrhous gastric cancer, gastric syphilis, and acute gastric mucosal lesion.

Case presentation

Case 1 A 32-year-old Asian man visited our hospital complaining of upper abdominal pain. Endoscopy raised suspicion of scirrhous gastric cancer. However, a histopathological examination showed no malignant cells, thus leading to the diagnosis of phlegmonous gastritis. The patient was started on antibiotic therapy, which was effective.

Case 2 A 33-year-old Asian man visited our hospital complaining of epigastralgia. Endoscopy raised suspicion of gastric syphilis. However, the serum test for syphilis was negative, and Streptococcus viridans was detected in the biopsy specimen culture, which led to the diagnosis of phlegmonous gastritis.

The patient was started on antibiotic therapy, resulting in significant improvement in the endoscopic image after 2 weeks.

Case 3 A 19-year-old Asian man visited our hospital complaining of epigastric pain. Endoscopy raised suspicion of acute gastric mucosal lesion. A gastric juice culture showed Pseudomonas aeruginosa and Streptococcus viridans , thus leading to the diagnosis of phlegmonous gastritis. The patient was started on antibiotic therapy, resulting in the disappearance of the gastric lesions.

In severe cases of phlegmonous gastritis, immediate surgical treatment is generally required. However, the endoscopic images are varied and nonspecific. These three cases suggest that clinicians need to consider the differential diagnosis of phlegmonous gastritis and make accurate diagnoses at an early stage.

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Phlegmonous gastritis is a rare and deadly infectious disease of the gastric wall, mainly occurring in the submucosa of the stomach. This disease is caused by suppurative bacterial infection and is conventionally managed by conservative treatment using antibiotics. In severe cases, such as perforation, urgent surgical treatment is required. Certainly, its mortality rate is not low. Therefore, this disease must be diagnosed correctly at an early stage. However, considering that the endoscopic images of phlegmonous gastritis are varied and nonspecific, making an early diagnosis is difficult. Herein, we report three cases of phlegmonous gastritis, each with unique endoscopic images, and consider a differential diagnosis. These cases were initially suspected of scirrhous gastric cancer, gastric syphilis, and acute gastric mucosal lesion. In severe cases, immediate surgical treatment is generally required. Therefore, accurate diagnoses and proper treatment need to be provided.

A 32-year-old Asian man visited our hospital, with complaints of epigastralgia, slight fever, and vomiting. He had a history of alcohol consumption (40 g/day) but had no medical history. His temperature was 37.4 °C. His white blood cell (WBC) count was 22,600/mm 3 , while his C-reactive protein level was 3.00 mg/dl. Abdominal computed tomography (CT) detected a thickened, edematous gastric wall.

Hence, the patient underwent esophagogastroduodenoscopy, which revealed a significant hyperplasia of the gastric folds with abundant mucopus, extensive redness and edema of the gastric mucosa, and poor distensibility of the gastric wall (Fig. 1 a). Considering this endoscopic image, scirrhous gastric cancer was suspected. On histopathological examination, mucosal necrosis and severe neutrophil infiltration were detected, with no malignant cells (Fig. 1 b).

a Endoscopic image of case 1. Significant hyperplasia of the gastric folds with abundant mucopus, and extensive redness and edema of the gastric mucosa were observed. b Histological image of case 1. Mucosal necrosis and neutrophil infiltration were detected, but no malignant cells were found

The clinical course (increased fever, epigastric pain, and elevated WBC count) as well as imaging (gastric wall thickness on CT and endoscopic findings) and histopathological findings led us to consider the serious infection and to diagnose the patient with phlegmonous gastritis, despite the biopsy specimen culture being negative.

Antibiotic therapy (levofloxacin, 500 mg/day × 7 days) was then provided, leading to the patient’s recovery.

A 33-year-old Asian man with epigastralgia visited our hospital. He had a history of excessive alcohol consumption (the exact amount was unknown), had no medical history, and was sexually active. The WBC count was 12,400/mm 3 . Abdominal CT detected localized thickening of the gastric wall, mainly in the antrum.

The endoscopic image revealed multiple shallow ulcers with slough fused into a map-like pattern in the same area (Fig. 2 a).

a Endoscopic image of case 2. Multiple shallow ulcers with slough fused into a map-like pattern were observed in the antrum. b Histological image of case 2. Immunostaining of the biopsy specimen was negative ( Treponema pallidum was not found)

Given the endoscopic findings, the patient was diagnosed with gastric syphilis. However, his serum test result for syphilis was negative, and the culture of biopsy specimen revealed the presence of Streptococcus viridans , resulting in the diagnosis of phlegmonous gastritis. In addition, immunostaining of the biopsy specimen was negative ( Treponema pallidum was not found) (Fig. 2 b). Thus, antibiotic therapy (amoxicillin, 750 mg/day × 14 days) was started. After 2 weeks, the endoscopic image revealed a remarkable improvement.

A 19-year-old Asian male college student visited our hospital, complaining of epigastralgia and vomiting. He had no history of drug and alcohol consumption and had no medical history. However, he had a fever (38.0 °C), with a WBC count of 15,900/mm 3 . Abdominal CT detected a thickened gastric wall, particularly in the antrum.

Endoscopic image showed large and shallow ulcers with reddish and edematous mucosa in the antrum, with some coagulation (Fig. 3 a). We initially suspected acute gastric mucosal lesion (AGML). However, the patient was eventually diagnosed with phlegmonous gastritis because Pseudomonas aeruginosa and S. viridans were found in the culture of gastric juice.

a Endoscopic image of case 3. Large and shallow ulcers with reddish and edematous mucosa were observed in the antrum, with some coagulation. b Histological image of case 3. Direct microscopy found no Helicobacter pylori

Meanwhile, the culture of gastric tissue was negative for Helicobacter pylori . Antibiotic therapy (tazobactam/piperacillin, 9.0 g/day × 10 days) was then started, and gastric lesions gradually disappeared.

H. pylori were not identified using direct microscopy in all cases (Fig. 3 b).

Phlegmonous gastritis is a rare inflammatory gastric disease caused by local or diffuse inflammation of the gastric wall [ 1 ]. The diffuse type is more common and has a higher mortality rate than the localized type. Case 1 was a diffuse type, whereas cases 2 and 3 showed a localized type. Imaging examinations are useful for diagnosing phlegmonous gastritis, which is suspected when gastric wall thickness is detected on abdominal ultrasonography or CT. Endoscopic ultrasonography for phlegmonous gastritis diagnosis is reportedly effective but is performed in few facilities [ 2 ].

By cause, phlegmonous gastritis is categorized into primary, secondary, and idiopathic types [ 3 , 4 ]. The most common is the primary type, which is caused by a mucosal injury such as peptic ulcer or gastric cancer. The secondary type is associated with the infection of other organs, such as biliary infection or hepatic abscess. It may also occur after endoscopic submucosal dissection and endoscopic ultrasound-guided fine-needle aspiration [ 5 , 6 ]. In the idiopathic type, as the name implies, the cause is unknown, and it mostly occurs in a compromised host. Moreover, cases 1 and 2 had a history of excessive alcohol consumption. Such a history is a causative factor of superficial gastritis, multiple small ulcers, and hemorrhagic erosions because alcohol can cause gastric mucosal injury, which induces phlegmonous gastritis [ 7 ]. Case 3 had no apparent background. However, he had an upcoming examination for promotion and felt extremely stressed. Mucosal injury such as AGML caused by mental stress could be the cause of phlegmonous gastritis [ 8 ]. Furthermore, temporary immunosuppression due to disruption in the rhythm of life might have triggered the onset of the disease in these three cases.

By clinical course, phlegmonous gastritis is categorized into acute, chronic, and subacute types [ 9 ]. All of our patients had a sudden onset of the disease, complaining of epigastralgia upon consultation. Therefore, they were categorized as the acute type.

The most common pathogenic cause of phlegmonous gastritis is Streptococcus (approximately 70%), which is resistant to gastric acid, followed by Enterococcus and Staphylococcus [ 10 ].

If the pathogen is found in the culture of gastric tissue or fluid, the diagnosis of phlegmonous gastritis could be made. However, pathogen is not always detected.

In case 1, although a pathogen was not identified, the patient was still diagnosed with phlegmonous gastritis because of other factors, such as the clinical course, symptoms, and imaging examinations.

Typically, the endoscopic image features of phlegmonous gastritis include reddish and edematous mucosa, swollen gastric folds, erosion, ulcer with slough, and mucopus adhesion. Considering that these features are nonspecific, various endoscopic images can be found in phlegmonous gastritis. Hence, we need to consider the differential diagnosis of phlegmonous gastritis.

Case 1 Scirrhous gastric cancer was suspected according to the following endoscopic image features: extensively reddish and edematous gastric mucosa, swollen gastric folds, abundant mucopus adhesion, and poor gastric wall distensibility.

Histopathologically, no malignancy was noted.

Obtaining a clinical history for several months is important because scirrhous gastric cancer takes a long time course.

Ultimately, imaging and histopathological examinations led to the diagnosis of phlegmonous gastritis.

Case 2 Gastric syphilis was suspected according to an endoscopic image feature, that is, multiple shallow ulcers with slough fused into a map-like pattern in the antrum. Furthermore, the patient was sexually active toward many unknown individuals. Regarding syphilis, the serum test and the immunostaining of the biopsy specimen were both negative ( Treponema pallidum was not found). However, S. viridans was detected in the culture; thus, the patient was diagnosed with phlegmonous gastritis.

When gastric syphilis is suspected, serum test and skin examination must be conducted.

Case 3 AGML was suspected because of the following endoscopic images: large and shallow ulcers with reddish and edematous mucosa and some signs of coagulation.

P. aeruginosa and S. viridans were found in the culture of gastric juice.

AGML is frequently caused by various factors, such as drugs (for example antibiotics, steroids, and nonsteroidal antiinflammatory agents), extreme mental or physical stress, and excessive alcohol consumption. Acute H. pylori infection must also be considered [ 11 ]. The patient had no history drug and alcohol intake and was negative for H. pylori infection. Considering that he had a history of mental stress, AGML caused by this stress was considered to be the cause of phlegmonous gastritis.

The treatment for phlegmonous gastritis is conservative treatment using antibiotics. However, surgical treatment is required in resistant or severe cases [ 12 ]. Given that fatal cases were occasionally reported, physicians need to make a correct diagnosis and start the appropriate treatment [ 13 ].

Availability of data and materials

There are no additional data available for this study.

Abbreviations

White blood cell

Computed tomography

• Acute gastric mucosal lesion

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Acknowledgements

We would like to thank Dr. Tomoaki Yamasaki of Osaka City General Hospital for correcting the English used in this manuscript.

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Yoshikazu Yakami, Toshihiko Yagyu & Tomoki Bando

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Yakami, Y., Yagyu, T. & Bando, T. Phlegmonous gastritis: a case series. J Med Case Reports 15 , 445 (2021). https://doi.org/10.1186/s13256-021-02999-9

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Chronic gastritis and gastroduodenal ulcer: a case control study on risk of coexisting duodenal or gastric ulcer in patients with gastritis.

Chronic (atrophic) gastritis (AG) is common in active duodenal (DU) and gastric ulcer (GU) disease. In this case control study in consecutive prospective outpatients (571 cases and 1074 controls) who had undergone diagnostic upper gastrointestinal endoscopy and routine biopsies from both antral and body mucosa, we calculated the risk of coexisting active DU and/or GU in different gastritis of the antrum or body and according to grade (superficial gastritis, mild, moderate or severe atrophic gastritis). The risk of coexisting active gastroduodenal ulcer (ulcer in duodenum and/or stomach), as well as the risk of DU or GU, was dependent upon the presence and grade of gastritis in antrum and body mucosa. The risk of coexisting ulcer, as expressed as an age adjusted relative risk (RR) and calculated as odds ratio of gastritis in cases and controls, was significantly increased in the presence of superficial antral and body gastritis (RR = 8.5 (7.0-20.0) in men; RR = 5.8 (3.3-10.2) in women), as compared with the risk of ulcer in subjects with histologically normal mucosa (RR = 1). The risk of ulcer, and the risk of GU in particular, increased further with increasing severity of antral gastritis. In such patients with moderate or severe atrophic antral gastritis the RR of coexisting ulcer even exceeded 20 in men and 10 in women (RR = 25.6 (9.0-72.7) in men; RR = 11.7 (5.9-23.0) in women). On the other hand, the RR of ulcer, and the RR of DU in particular, was below 1 in the presence of atrophic gastritis in the gastric body, irrespective of the grade of gastritis in the antrum. We conclude that the type and grade of gastritis strongly predicts the risk of coexisting peptic ulcer, and that the risk of coexisting DU or GU increases with an increase in grade of AG of the antrum but decreases with an increase in grade of AG of the gastric body.

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Patient Case Presentation

Vital Signs and Measurements

• BP: 135/85 mm Hg
• HR:  99 bpm
• RR: 21 b / min
• Temperature: 36.1 ℃
• Pulse oxygenation: 99%
• Height: 167 cm
• Weight: 58.2 kg

Past medical history

• Gastritis with  Helicobacter pylori (H. pylori) infection, diagnosed 5 years ago. Resolved with pharmacotherapy, frequent recurrence.
• Heart attack 3 months ago, has started taking aspirin since then.
• Osteoarthritis, diagnosed 3 years ago. Long-term use of the non-steroidal anti-inflammatory drug (NSAID) since diagnosis.
• Acute pancreatitis 5 years ago, resolved with pharmacotherapy, no recurrence.
• Chronic obstructive pulmonary disease, diagnosed 11 years ago.
• Diabetes Mellitus and hypertension diagnosed 6 years ago.
• No surgical history.

Pertinent family history

• Mother died from gastric cancer at age 67 years old.
• Father alive, has smoked for 50 years and now has a small-cell carcinoma. Live with the patient since she divorced her husband.
• Brother alive and well at age 56 years, had a history of duodenal ulcers. Heavy smoker.
• Ex-husband at age 62, alive and has COPD.
• One son alive and well at age 29.
• One daughter at age 35, alive and has recurrent Gastritis.

Pertinent social history

• Has worked full-time as a TV program producer for 30 years.
• Divorced with her husband 20 years prior, raised 2 children by herself.
• Hobbies include drinking, eating spicy food, watching dramas and talkshow.
• Has smoked for 30 years, even after the diagnosis of COPD, still cannot quit smoking.

A Patient/Family Care Study on Gastritis

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Case Study on Acute Gastroenteritis

Gastroenteritis, sometimes referred to as “stomach flu”, is an inflammation of the GI (gastrointestinal) tract, which includes the stomach and intestines. Most cases of gastroenteritis are caused by viruses. Bacterial gastroenteritis (caused by bacteria) often causes severe symptoms. It can even be fatal. It is also the most common digestive disorder among children. Severe gastroenteritis causes dehydration and an imbalance of blood chemicals (electrolytes) because of a loss of body fluids in the vomit and stool. This can be acquired through contaminated food and water that contains harmful bacteria (such as salmonella, Campylobacter, and E. coli). Food can be contaminated when food handlers don’t wash their hands. Or when food isn’t stored, handled, or cooked correctly. This can also be acquired and spread through the fecal-oral route, people with gastroenteritis have harmful bacteria in their stool. When they don’t wash their hands well after using the bathroom, they can spread the germs to objects. If you touch the same objects, you can pick up the germs on your hands and transfer them to your mouth. (Fairview.org, 2021)

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