From the Department of Diagnostic Radiology, Ewha Women's University College of Medicine (B. C. Kang and S. W. Lee), and Department of Diagnostic Radiology, Yonsei University College of Medicine (K. W. Kim and J. H. Kim), Seoul, South Korea.
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Gastric wall abscess is very rare and occasionally presents with the radiologic features of a submucosal lesion, in particular closely mimicking a leiomyoma (1). The mortality of gastric wall abscess has been reported as 90-95% (2), and various methods for treatment have been recommended (1-5). The characteristic imaging features of gastric wall abscess have not been reported, to our knowledge. We describe the characteristic findings of gastric wall abscess on CT and ultrasound with power Doppler study, which was successfully treated by endoscopic drainage and antibiotics.Case ReportA 27-year-old woman presented with a rare gastric wall abscess with a history of right upper quadrant pain and tenderness for 1 week. With a clinical impression of acute cholecystitis, transabdominal sonography revealed a hypoechoic round mass with posterior enhancement at the posterior wall of the gastric antrum (Fig. 1A), which showed increased vascular signals around the hypoechoic lesion on power Doppler examination (Fig. 1B). Contrast-enhanced CT demonstrated a oval-shaped low density lesion in the posterior wall of the gastric antrum associated with diffusely thickened and enhanced gastric walls(Fig. 1C). Endoscopic ultrasonography confirmed the presence of the hypoechoic mass at the submucosal layer of the posterior wall of the gastric antrum (Fig. 1D). The possibility of intramural gastric abscess was considered rather than gastric carcinoma because of the presence of turbid fluid drained through the hole made by piercing the submucosal mass with the endoscopic biopsy needle(Fig. 1E). After that, upper gastrointestinal series showed focal contour irregularity at the greater curvature side of the antrum(Fig. 1F). This patient was treated by endoscopic needle drainage, antibiotics, and abstinence of food. Endoscopy obtained 1 month after treatment showed only focal mucosal scar at the piercing point of the gastric antrum. She was discharged without any symptoms, and symptoms have not recurred.DiscussionGastric wall abscess has been generally regarded as a secondary phenomenon to hematogenous spread complicating pneumonia, erysipelas, typhoid fever, diphtheria, furunculosis, puerpural sepsis, bronchitis, osteomyelitis, and bacterial endocarditis (2-4) or local invasion of the gastric mucosa with bacteria either ingested/refluxed from the proximal intestine (2,3,5,6). The normal stomach harbors low numbers of bacterial organisms because of its high acidity. So usually it is sterile (4). However, when the protective action of gastric acid is absent, bacterial overgrowth can occur. This phenomenon has been reported in the elderly and in patients with achlorhydria, gastric ulcer, and gastric carcinoma(7). Thus, a primary gastric abscess is very rare, and, to our knowledge, two cases have been described with barium study, the most likely cause of which would appear to be a foreign body, such as a fish bone(1). Other sources of bacteria within the gastric wall are endoscopic instrumentation, implanting a small inoculum in the gastric mucosa with the original biopsy, and cimetidine changing the bacterial flora of the stomach (1,8). A secondary gastric wall abscess was reported as a well defined heterogeneous hypoechoic lesion with endoscopic ultrasonography (9).Diagnosis of a primary gastric wall abscess is not difficult but requires a high degree of suspicion because of its rarity. Findings on the ultrasonogram with power Doppler examination can be useful to diagnose.