UJMS 110 (3) bra


Upsala J Med Sci 110 (3): 237–240, 2005

Emergency Operation for Phlegmonous Gastritis

Takashi Yokota1, Takayuki Yamaki2, Rei Yashima2,  Yasuo Yamada2,  Yoichi
Narushima2, Shu Kikuchi2, Hidemi Yamauchi2 and Masahito Hatori3.

1Department of Surgery, National Sanatorium Tohoku Shinseien, 2 Department of Surgery, Sendai
Medical Center and 3Department of Orthopaedic Surgery, Tohoku University School of Medicine,

Sendai, Japan.

ABSTRACT

Phlegmonous gastritis is a rare inflammatory lesion in which bacterial infection occurs
in the gastric wall. A case of phlegmonous gastritis producing an intramural filling
defect in the stomach is presented. Endoscopy showed edematous and reddened gastric
mucosa with a mass lesion in the gastric body and antrum. An abdominal CT scan
showed diffuse and irregular thickening of the gastric wall. At emergency operation, a
total gastrectomy with splenectomy was performed. The most important differential
diagnosis is carcinoma, especially scirrhous-type gastric cancer. Radiographic findings
of phlegmonous gastritis resemble those of scirrhous gastric cancer. More frequent
recognition of this disease, early diagnosis and prompt institution of treatment is essen-
tial.

INTRODUCTION

Phlegmonous gastritis is a rare inflammatory lesion of the gastric wall. Although the
disease usually shows characteristic macroscopic and histological findings1, the
diagnosis may contribute to problem and it is sometimes difficult to distinguish
phlegmonous gastritis from scirrhous gastric cancer. In this report we describe a
case of phlegmonous gastritis with an acute clinical course where emergency opera-
tion was necessary.

CASE REPORT

A 74-year-old woman was sent to the Sendai Medical Center in June 2002 because
of abdominal pain and vomiting of one-week duration. On admission, the patient
was drowsy. Physical examination revealed tenderness in her upper abdomen with
sluggish bowel sounds. Blood pressure was 130/65 mmHg, and pulse rate was 55

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Received 11 April 2005
Accepted 23 May 2005
Key words: phlegmonous gastritis, scirrhous gastric cancer



beats/min and regular. Her temperature was 38.5°C. Laboratory examination
showed a white blood cell count of 28.3x109/L; hemoglobin of 129g/L; normal
serum sodium, potassium and chloride levels; serum calcium level of 5.5 mmol/L;
serum phosphorus level of 1.9 mmol/L blood urea nitrogen of 2.9 mmol/L; and a
serum creatinine level of 0.8 mg/dl. Liver enzymes were normal. The patient was
aggressively treated with fluid resuscitation. One day after the start of treatment,
serum calcium level had decreased to 2.5mmol/L. An abdominal CT scan showed
diffuse and irregular thickening of the gastric wall (Fig. 1a). An upper gastrointesti-
nal series showed narrowing of the antrum and pylorus involving almost the entire
gastric cardia, mimicking Borrmann type 4 gastric cancer of “linitis plastica” (Fig.
1b). At gastroscopy, the stomach mucosa had a thinned atrophic appearance, with
numerous white nodules scattered irregularly throughout the body and fundus of the
stomach. The nodules varied in size, with the largest being approximately 2-3 mm
in diameter. A stricture was observed in the stomach body (Fig. 1c). The patient’s
symptoms worsened during the next 5 days, and she developed nearly complete
gastric outlet obstruction secondary to an annular construction of the antrum. No
ulceration was seen. Examination of a biopsy specimen from the gastric mucosa
revealed severe inflammation. Since an upper GI series demonstrated typical fea-
tures of Borrmann type 4, we suspected that it was cancerous lesions. An emer-
gency operation was performed. On laparotomy, a total gastrectomy with splenecto-
my was performed. Adhesion between the stomach and spleen was very strong, and
we could not separate them. It was easier to resect the stomach and spleen as one
organ. The stomach wall was thickened and edematous with diffuse ulceration.
Microscopic examination showed the gastric mucosa to be infiltrated by lympho-
cytes. The submucosa was edematous and infiltrated by inflammatory cells with a
focal area of necrosis (Fig. 1d).

DISCUSSION

Very little is known about the pathogenesis of phlegmonous gastritis. In most cases,
hemolytic streptococcus is reported to be the offending organism (1). There are
three possible routes of spread: 1) direct injury to gastric mucosa due to sharp bones
or other hard food, 2) hematogenous spread from some other septic focus such as
endocarditis, and 3) lymphatic spread from a septic focus. Some researchers pro-
duced a submucosal abscess in dogs by introducing streptococci into the mucosal
surface after induction of alcohol gastritis, but others failed to produce a similar
condition1. Until more is known about the mechanism of gastric defense in response
to bacterial invasion, the pathogenesis of this disease will remain unclear. Patients
with this disease present with an acute abdomen, with intense epigastric pain of rel-
atively rapid onset associated with epigastric guarding (2). Leucocytosis and nausea
and vomiting are present. In the most fulminant varieties, the patient develops
severe toxemia and early peripheral circulatory collapse (3). There are few descrip-

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tions of radiographic findings of phlegmonous gastritis (4). The common features
seem to be a relatively small intramural mass, often in the antrum of the stomach,
usually without destruction of the overlying mucosa. The mucosal folds are com-
pletely effaced at the site of involvement. There is frequently gastric retention of
barium, and complete pyloric obstruction has been reported. The most important
differential diagnosis is carcinoma; actually, the preoperative diagnosis in our
patient was scirrhous-type gastric cancer in spite of a “negative” biopsy. Scirrhous
type carcinoma cells invade extensively under the mucosal layer, and results of
biopsy examination are sometimes negative. Radiographic findings of plegmonous
gastritis resemble those of scirrhous gastric cancer. Scirrhous gastric cancer is clini-
cally characterized by diffuse infiltration by cancer cells and shows significant
thickening of the gastric wall with no prominently elevated or depressed lesions (5).
The infiltrative carcinoma may grow either superficially over the surface of the
mucosa or permeate the entire thickness of the wall, producing a pattern known as
linitis plastica. A submucosal biopsy has potential diagnostic benefit.

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Figure 1a: Abdominal CT showed diffuse and irregular thickening of the stomach body wall (arrow).
b: Barium examination of the upper gastrointestinal tract revealed a marked large irregular filling
defect involving the entire gastric wall (arrow). c: Endoscopy showed edematous and reddened gastric
mucosa with a stricture in the gastric body. d: A gastric section showing diffuse inflammatory swelling
of submucosa with involvement of the muscularis. (original magnification, x100)

a b

dc



There is a lack of agreement about the role of surgery in the management of acute
phlegmonous gastritis, some authors recommending antibiotic therapy alone and
others recommending gastrectomy or gastrotomy for drainage of submucosal
abscesses1-3. Early diagnosis and prompt institution of treatment with or without
surgery are essential for this disease.

REFERENCES

1. Miller AI, Smith B, Rogers AI (1975) Phlegmonous gastritis. Gastroenterology 68: 231-238.
2. Iwakiri Y, Kabemura T, Yasuda D (1999) A case of acute phlegmonous gastritis successfully

treated with antibiotics. J Clin Gastroenterol 28: 175-177.
3. Webster VJ (1980) Necrotizing gastritis and phlegmonous gastritis-are they separate entities?

Aust NZ J Surg 50: 194-196.
4. Sood BP, Kalra N, Suri S (2000) CT features of acute phlegmonous gastritis. Clin Imaging 24:

287-288.
5. Yokota T, Teshima S, Saito T (1999) Borrmann type IV gastric cancer: Clinicopathological

analysis. Can J Surg 42: 371-376.

Corresponding author: Takashi Yokota, M.D.
National Sanatorium Tohoku Shinseien
Hasama, Tome, Miyagi 989-4601, Japan
_:0228-38-2121, fax: 0228-38-3765, 
e-mail address: HKI06124@nifty.com

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