Endoscopic treatment of a gastric abscess

J Gastrointestin Liver DisMarch 2007 Vol.16 No 1, 113-115Address for correspondence:

A Pyogenous Gastric Abscess that Developed FollowingIngestion of a Piece of a Wooden Skewer: Successful Treatmentwith Endoscopic Incision

Panagiotis Katsinelos1, Grigoris Chatzimavroudis1, Christos Zavos2, Ioannis Triantafillidis1, Jannis Kountouras2

1) Department of Endoscopy and Motility Unit, “G.Gennimatas” Hospital. 2) Department of Medicine, Second MedicalClinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece

Dr. Panagiotis KatsinelosDept. Endoscopy and Motility Unit“G.Gennimatas” HospitalEthnikis Aminis 41546 35 Thessaloniki, GreeceE-mail: gchatzim@med.auth.gr

AbstractA 62-year-old man with a medical history of duodenal

ulcer was referred to our department for endoscopy, becauseof epigastralgia associated with mild anorexia. At endoscopy,a large protruding lesion with the appearance of a submucosaltumor was present at the posterior wall of the gastric body.Trying to perform an aspiration needle biopsy for cytologicalstudy, we observed the outflow of pus from the puncturepoint. An incision, 1 cm in length, was performed via a needle-knife sphincterotome, which led to drainage of the abscessand disappearance of symptoms. A 2.5 cm long piece of awooden skewer was found to be embedded into the area ofthe bulge and was retrieved.

Key wordsGastric abscess - wooden skewer - endoscopic treatment

IntroductionAlthough the ingestion of foreign bodies into the

gastrointestinal tract is a common occurrence, subsequentperforations or other complications are relatively rare, asmost foreign bodies pass through the gut uneventfully (1,2).Once a perforation due to foreign body ingestion does occur,it is usually presented in the form of an intra-abdominalabscess (1-4). The occurrence of an abscess in a solid organ,such as the liver, or in a hollow organ, such as the stomach,is extremely rare.

We describe the first case of a pyogenous gastricabscess, resulting from a piece of a wooden skewer embed-ded in the gastric mucosa that was treated endoscopically.

Case reportA 62-year-old man was referred to our department for

endoscopy by his general practitioner, because of a 10-dayhistory of epigastric pain radiating to the back andassociated with mild anorexia.

Apart from an appendectomy 30 years ago and a historyof duodenal ulcer, there was no remarkable past medicalhistory. Clinical examination revealed moderate tendernessin the upper epigastrium. The patient was not febrile.

Upper endoscopy showed a bulging mass in the posteriorwall of the gastric body, covered with normal-appearingmucosa (Fig.1). A gastric leiomyoma was suspected andtherefore an aspiration biopsy with an 18-G needle (BAN-18, Wilson-Cook Medical Inc, Winston-Salem, USA) wasattempted for cytological analysis. The puncture of thebulging mass with the needle resulted in the outflow ofpus. Using a needle-knife sphincterotome (HPC-2, Wilson-Cook Medical Inc, Winston-Salem, USA), an incision wasmade, 1 cm long, which was sufficient for the flow of pusand for the complete disappearance of the bulging mass(Fig.2). Embedded into the area of the bulging, a 2.5 cmpiece of a wooden skewer was observed, which wassubsequently removed (Fig.3).

When questioned, the patient remembered that 20 daysearlier, he had accidentally swallowed a piece of meat thatcontained a piece of a stick, while eating a traditional Greekmeal, which is made by small pieces of pork meat piercedwith a wooden skewer. He had given little thought to thisincident since he had no symptoms.

The post-procedure course was uneventful. The patientshowed complete relief of epigastric pain, and he wasdischarged from the hospital, completely asymptomatic, twodays later.

DiscussionMost ingested foreign bodies pass through the gastro-

intestinal (GI) tract uneventfully within one week. Gastro-intestinal perforation is rare, occurring in less than 1% of

Katsinelos et al114

Fig.1 A. Endoscopic view ofa large protruding lesion in theposterior wall of the gastricbody. B. Close-up endoscopicview showing the appearanceof a submucosal tumor.

Fig.3 The removed piece of the wooden skewer,measuring 2.5 cm in length.

Fig.2 Endoscopic view of pus outflow and massregression after endoscopic incision with a needle-knife sphincterotome.

patients (1). When symptoms arise, they are usuallysecondary to obstruction or, possibly, peritonitis (1,2).Perforation has been reported to occur from toothpicks,sewing needles, fish bones, chicken bones and dental plates(1-4). Foreign body perforation usually results in thedevelopment of peritonitis, an intra-abdominal abscess, or,very rarely, after migration of the object into an adjacentsolid organ such as the liver, abscess formation. The firstcase of hepatic abscess secondary to foreign bodyperforation was reported by Lambert in 1896 (5). Since then,several cases of hepatic abscesses secondary to sharpforeign bodies have been reported (6-14). Recently, Goh etal (15) reported a case of a pancreatic mass secondary tofish bone perforation of the GI tract with migration into thepancreas.

To the best of our knowledge, only one case of gastricabscess due to a fish bone has been reported. Fernandez-Urien et al (16) reported a 49-year-old woman who presentedwith epigastric discomfort and vomiting for several monthsduration. Physical examination and standard laboratoryresults were normal. At upper GI endoscopy, a 15 mm wideulcerated, protruding lesion, with the appearance of asubmucosal tumor, was present in the prepyloric area of theantrum. Endoscopic ultrasonography showed a hypoechoic,nodular, poorly demarcated lesion, with a heterogeneousinternal echo pattern, and a linear, highly echogenicstructure. A GI stromal tumor was suspected, and the lesionwas resected laparoscopically. The resection specimenconsisted of a 13 mm nodular, ulcerated, submucosal lesionwith an internal cavity that contained dense pus and aforeign body that proved to be a fish bone.

The preoperative diagnosis of complications fromforeign body ingestion is often difficult, as patientsfrequently give no history of swallowing the foreign body,or may remember the incident only after the diagnosis ismade (6). This is especially true if the foreign body issomething commonly ingested and, therefore, forgotten,such as a toothpick or a chicken/fish bone. Furthermore,there may be a considerable time lag, ranging from days tomonths or even years, between the time of ingestion andthe onset of symptoms (1,2).

We postulate that our patient ingested the piece of thewooden skewer, which was embedded in the middle of theposterior wall of the gastric body, resulting in the formationof a gastric abscess. The diagnosis of a gastric abscess dueto an embedded foreign body was not suspected in ourpatient for several reasons: (a) there was no history of foreignbody ingestion, (b) the patient was not febrile, (c) there wasa history of duodenal ulcer, which led us to consider anulcer recurrence as the most probable cause of thesymptoms, and therefore to proceed to immediateendoscopy without previous laboratory testing orradiological imaging.

In conclusion, this case demonstrates an unusualpresentation of a piece of a wooden skewer embedded intothe gastric mucosa, which resulted in the development ofan abscess. It illustrates the difficulty in making thediagnosis, unless a high index of suspicion is maintained. Italso serves as a reminder to all endoscopists that thediagnosis of a complication due to foreign body ingestion

Endoscopic treatment of a gastric abscess 115

should always be kept in mind, even in the absence of feveror other clinical signs of infection.

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foreign bodies of the gastrointestinal tract: retrospectiveanalysis of 542 cases. World J Surg 1996; 20: 1001-1005

2. Weissberg D. Foreign bodies in the gastro-intestinal tract. S AfrJ Surg 1991; 29: 150-153

3. Maleki M, Evans WE. Foreign-body perforation of the intestinaltract. Report of 12 cases and review of the literature. Arch Surg1970; 101: 475-477

4. McCanse DE, Kurchin A, Hinshaw JR. Gastrointestinal foreignbodies. Am J Surg 1981; 142: 335-337

5. Lambert A. Abscess of the liver of unusual origin. NY Med J1892; 2: 177-178

6. Shaw PJ, Freeman JG. The antemortem diagnosis of pyogenicliver abscess due to perforation of the gut by a foreign body.Postgrad Med J 1983; 59: 455-456

7. De la Vega M, Rivero JC, Ruiz L, Suarez S. A fish bone in theliver. Lancet 2001; 358: 982

8. Theodoropoulou A, Roussomoustakaki M, MichalodimitrakisMN, Kanaki C, Kouroumalis EA. Fatal hepatic abscess causedby a fish bone. Lancet 2002; 359: 977

9. Dugger K, Lebby T, Brus M, Sahgal S, Leikin JB. Hepatic abscess

resulting from gastric perforation of a foreign object. Am JEmerg Med 1990; 8: 323-325

10. Horii K, Yamazaki O, Matsuyama M, Higaki I, Kawai S, SakaueY. Successful treatment of a hepatic abscess that formedsecondary to fish bone penetration by percutaneous transhepaticremoval of the foreign body: report of a case. Surg Today1999; 29: 922-926

11. Chan SC, Chen HY, Ng SH, Lee CM, Tsai CH. Hepatic abscessdue to gastric perforation by ingested fish bone demonstratedby computed tomography. J Formos Med Assoc 1999; 98: 145-147

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References1. Watkins RM. Treatment of parastomal haemorrhage. Br J

Surg. 1983;70:128-129.2. Adson MA, Fulton RE. The ileal stoma and portal hypertension:

an uncommon site of variceal bleeding. Arch Surg.1977;112:501-504.

3. Shibata D, Brophy DP, Gordon FD, Anastopoulos HT, SentovichSM, Bleday R. Transjugular intrahepatic portosystemic shuntfor treatment of bleeding ectopic varices with portalhypertension. Dis Colon Rectum 1999; 42:1581-1585.

Quiz HQ - 36, page 83. Answers1. This patient has varices around the mucus fistula from

which the bleeding occurred as a result of portal hyper-tension complicating primary biliary cirrhosis. Theoccurrence of varices has previously been described aroundthe stoma; however, its occurrence around a mucus fistulahas not been described previously to the best of ourknowledge.

2. These varices arise at the border of the muco-cutaneous junction of the stoma as a result of anastomosesbetween the high-pressure portal circulation and the low-pressure systemic venous system.

3. Several treatment strategies have been advocated forstomal variceal haemorrhage, including direct pressure,suture ligation, injection sclerotherapy and mesentericvenous embolization. These methods, however, have highrates of re-bleeding and the major complication of mesentericembolization is mesenterico-portal thrombosis with intestinalinfarction which carries a significant mortality.

Three surgical treatments have been described. Completerevision of the stoma requires laparotomy with its attendantrisks and complications. Portocaval shunting to reduce portal

hypertension has also been successfully used but carriessimilar perioperative risks. Mucocutaneous disconnectionis an alternative and a less invasive means of surgicalintervention. This procedure involves dissection of theperistomal tissues and direct ligation of the portosystemicvascular connections at the mucocutaneous junction.

Recently, transjugular intrahepatic porto-systemic shunt(TIPS) with variceal embolization offers an effective,minimally invasive management option in patients withbleeding stomal varices, and may be used as the primarymode of intervention in conjunction with medical therapy,and as the definitive therapy in patients unfit for surgery.