Phlegmonous gastritis following coronary bypass surgery

Phlegmonous gastritis is a rare disease with a high mortality rate. It has been described in association with peptic ulcer, gastric carcinoma, alcoholic liver disease, diabetes mellitus, invasive gastroscopic manipulation, oral intoxication with caustic substances, Sjögren’s syndrome and acquired immunodeficiency syndrome (1-4). It is most often caused by streptococci, and other organisms such as staphylococci, Escherichia coli, pneumococci, enterobacter and Klebsiella species have also been implicated. Prompt recognition of phlegmonous gastritis by endoscopic biopsies and bacteriological sampling may improve the prognosis of these patients (5).

thickened, and the serosa was pale and edematous.There was no evidence of peptic ulceration or malignancy, and no atheromatous changes of the celiac axis or its main branches.Microscopic examination showed mucosal necrosis, submucosal edema, vascular thrombosis and transmural inflammation with no muscle necrosis (Figures 1,2).Higher magnification showed a predominantly polymorphonuclear leukocyte infiltrate (Figure 3).Gram stain demonstrated Gram-positive diplococci and Gram-negative bacilli.The overall appearance was consistent with phlegmonous gastritis.Culture was not performed.The liver weighed 1300 g and showed severe chronic venous congestion with no cirrhosis.There was no evidence of any septic focus or other significant pathology.

DISCUSSION
Phlegmonous (suppurative) gastritis is the term used to describe acute suppurative inflammation of the stomach wall.The mortality associated with this disease continues to be high because it is often not recognized.This is in part due to the lack of clinical suspicion, and nonspecific signs and symptoms.Most of the cases reported in the literature as well as this case were not suspected clinically, but rather were discovered at autopsy, or after studies of surgical specimens from patients in whom the diagnosis was not made preoperatively.Most cases involved patients in the 30 to 60 years age group, but there is a wide age range (6).Clinical features are usually of a rapid onset with upper abdominal pain, tenderness, nausea and vomiting, and rarely upper gastrointestinal bleeding.Physical findings often include fever, peritoneal signs and occasionally a palpable mass.Fever, chills and severe prostration are ominous signs of bacteremia and septicemia.Upper gastrointestinal tract endoscopy often shows a dilated stomach with edematous folds and rigidity of the antrum (7).Laboratory examination often reveals polymorphonuclear leucocytosis and occasionally positive blood culture (1,8).Concomitant bacterial infection is often present in a variety of sites.Phlegmonous gastritis most commonly involves the stomach in a diffuse fashion, although the entire gastrointestinal tract may be affected (6).Occasionally a chronic form develops within the stomach wall due to organization of the acute inflammatory exudate and fibrosis (9).
Histological examination demonstrated acute inflammation of the submucosa with extension to the muscle coat and the serosa.Thrombosed vessels are commonly found in the edematous submucosa.
Alpha-hemolytic streptococci are the organisms most frequently implicated.Other organisms such as staphylococci, pneumococci, E coli, enterobacter, Klebsiella species and Clostridium perfringens have also been isolated (4).Mixed bacterial infections have been reported.No culture was performed in this case.
Our patient developed gastric symptoms following bypass surgery, complicated by gastric bleeding.The pathogenesis of this condition remains unclear.It has been suggested that bacteria may enter the gastric mucosa after mucosal injury.In some cases there is a pre-existing gastric pathology such as peptic ulcer or carcinoma that might permit entry of micro-organisms.It is not known by which route the infection is acquired.One possibility is direct spread from the gastric lumen due to ingestion of infected respiratory tract secretion, in which case acute or chronic gastritis may act by reducing acid secretion and providing a portal of entry through damaged mucosa.This is the most likely explanation for the phlegmonous gastritis in this patient.The second route is blood-borne infection spread to the stomach from a distant focus (9,10 ).However, autopsy did not reveal any other site of infection in this case.
The literature includes reports of phlegmonous gastritis associated with alcoholic liver disease, diabetes mellitus, Sjögren's syndrome, human immunodeficiency virus-1 seroconversion and adult T cell leukemia (1,2,11).The increased risk in these patients is related to an innate susceptibility.Most patients succumb because of septicemia.The disease may appear to be confined to the stomach in the early stages; however, subsequent spread to the rest of the gastrointestinal tract may follow.Although this is an extremely rare condition, clinicians need to be aware of this condition because the prognosis is related to the speed of recognition and the treatment.The overall mortality rate is 67%.Partial or total gastrectomy combined with antibiotic therapy is the most appropriate regimen and is reported to reduce mortality in about 20% (10).