Delayed gastric emptying and microorganisms in tetrads
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An 83-year-old woman with a stage IV ovarian adenocarcinoma presented with a 1-week history of recurrent vomiting and intermittent cramping abdominal pain. A positron emission tomography scan performed a few months prior revealed enhancing hypermetabolic nodules in the greater curvature and pylorus of the stomach. Computed tomography performed upon admission revealed stomach distension and irregular pyloric wall thickening causing severe narrowing (Fig. 1). Subsequent esophagogastroduodenoscopy revealed a fluid-filled stomach, and 1.1 L of content was suctioned despite a fast exceeding 24 hours (Fig. 2). Other findings included esophagitis, diffuse erosive gastritis, and severely edematous pyloric channels. There were no endoscopic findings of tumor infiltration, and a scope was used to intubate the pylorus with insufflation. Targeted mucosal biopsies (Fig. 3) revealed mild chronic inflammation with bacterial organisms in tetrads compatible with Sarcina ventriculi (Fig. 4), a commensal gram-positive anaerobic bacteria that thrives at a very low pH.1 Few cases have been published; in most reports, infection was associated with delayed gastric emptying from gastroparesis or pyloric stenosis.2 In cases of co-existent mucosal damage, infection has been associated with emphysematous gastritis, ulcers, and even perforations.3 In our immunocompromised patient, the S. ventriculi overgrowth probably resulted from prolonged exposure to a low pH environment due to the delayed gastric emptying. The resulting inflammation further exacerbates the impaired gastric motility. A diagnosis is achieved through histopathologic identification, and antibiotic treatment reduces complications.2 During treatment with metronidazole and piperacillin tazobactam, her symptoms improved, and a soft diet was tolerated with no recurrence of the vomiting. Endoscopy with repeat biopsies performed 1 month later confirmed infection eradication, inflammatory resolution, and reduced pyloric edema. This case demonstrates that targeted mucosal biopsies should be performed in immunocompromised patients with delayed gastric emptying and mucosal inflammation. The detection of S. ventriculi should alert clinicians of its underlying cause and prompt treatment to prevent potential severe complications.
Abdominal computed tomography scan performed at the level of the pylorus and stomach showing stomach distension and irregular wall thickening in the pylorus.
Endoscopic view of the gastric body showing a distended fluid-filled stomach.
Targeted biopsies were taken from: (A) the edematous pyloric opening; and (B) a hyperemic patch at the greater curvature of the stomach.
Microorganisms within the tetrads found during the gastric mucosal biopsy (H&E stain, HPO 40× magnification).
Notes
Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.
Acknowledgments
Informed consent was obtained for the publication of this case report.
Author Contributions
Conceptualization: EJA; Data curation: MAG, MRD; Supervision: EJA, IHC; Writing–original draft: MAG, MRD; Writing–review & editing: EJA, IHC.