Although pain is a common complication of endoscopic submucosal dissection (ESD), management strategies are inadequate. The aim of this study was to evaluate the efficacy of topical bupivacaine and triamcinolone acetonide for abdominal pain relief and as a potential method of pain control after ESD for gastric neoplasia. In this randomized, double-blind, placebo-controlled trial, 111 eligible patients with early gastric neoplasm were randomized into one of three groups: bupivacaine (BV) only, bupivacaine with triamcinolone (BV-TA), or placebo. The present pain intensity (PPI) score and the Short-Form McGill Pain Questionnaire (SF-MPQ) were used to evaluate pain at 0, 6, 12, and 24 h after ESD. The mean values for the 6-hour PPI in the BV-TA and BV groups were lower than those of the placebo group (1.57 ± 1.09 and 1.97 ± 1.09 vs. 2.63 ± 0.98, p < 0.001). The 12-hour PPI of the BV-TA group (1.20 ± 0.83) was the lowest among the three groups (p = 0.001). The total 6-hour SF-MPQ score, especially in the sensory domain, was higher in the placebo group than in BV and BV-TA groups. The 12-hour SF-MPQ score was the lowest in the BV-TA group. Multivariate analysis demonstrated that BV-TA injection protocol, fibrosis, and size of residual ulcer were independently associated with the PPI score at 6 h. Bupivacaine after ESD was effective for pain relief at 6 h postoperatively. Particularly, topical infiltration of bupivacaine mixed with triamcinolone acetonide was helpful for producing a more long-lasting benefit of pain relief after gastric ESD.

The efficacy of topical bupivacaine and triamcinolone acetonide injection in the relief of pain after endoscopic submucosal dissection for gastric neoplasia: a randomized double-blind, placebo-controlled trial.

Phlegmonous gastritis is a rare bacterial infection of the gastric wall, which progress rapidly. It is characterized by a purulent inflammation that can affect the entire gastrointestinal tract and presents a high mortality rate. We are reporting a case of phlegmonous gastritis in an HIV-seropositive man successfully treated with antibiotics. Moreover, a review of the English andSpanish literature is carried out, from 1980 to the present time.The most frequently involved microorganism is Streptococcus spp. (57 %), but the polimicrobial infection is also frequent (17 %). The most important symptom is the intensive epigastric pain associated with vomits and most cases were diagnosed by CT and/or fibrogastroscopy. There are many existing risk factors described.The main one is the immunesuppression, although in 40 % of the cases no risk factors were identified. The global mortality is 27 % without identifying significant differences between antibiotics and surgical treatment, for that reason it is recommended to initiate antibiotic treatment right from the beginning and postponing surgery for the refractory cases and complications.

/pdf/phlegmonous-gastritis-a-rare-entity-as-a-differential-4qlnjxxxgg.pdf

Phlegmonous gastritis: A rare entity as a differential diagnostic of an acute abdomen. Description of a case and a bibliographic review.

Gastric biopsies are often submitted with as clinical question Helicobacter pylori (HP) infection. Regularly, the morphology suggests a HP infection but the organism is not detected in special stains. This review presents a practical approach to deal with such biopsies. The first step is to exclude a false negative result of the search for HP, by ensuring that both antral and oxyntic mucosa are present, by the use of sensitive stains, identification of marked reactive changes, such as intestinal, pseudo-pyloric, pancreatic metaplasia that may suggest a diagnosis of (HP associated or autoimmune) atrophic gastritis, and finally identification of signs of the use of proton pump inhibitors (PPI) as in such biopsies, HP may sometimes be found only within parietal cells. The differential diagnosis should include lymphocytic gastritis, other diseases affecting the stomach, such as inflammatory bowel disease (IBD), vasculitis, granulomatous disease, viral infection, such as cytomegalovirus (CMV) or more rarely Epstein-Barr virus (EBV) infection, or other bacterial infections, such as Enterococcus and Treponema pallidum. Clinical input may be required to ensure the patient is not taking medication that may cause gastritis, such as antibiotics used for HP eradication or common medications that cause a form of gastropathy. When these have been excluded, a known cause has not been found and in such a case, the term idiopathic focal/diffuse gastritis can be used.

The differential diagnosis of Helicobacter pylori negative gastritis

Phlegmonous gastritis (PG) is a rare, often fatal, condition characterized by suppurative bacterial infection of the stomach. Mucosal damage of the stomach, alcoholism and an immunocompromised state are predisposing factors. Phlegmonous gastritis rarely develops after therapeutic endoscopy and only a few instances have been reported. We describe a patient with PG that arose as a complication after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). A 70-year-old woman with a diagnosis of pancreatic tumor attended our hospital. A 50-mm, low echoic lesion at the pancreatic body was identified by EUS and EUS-FNA proceeded through the stomach using a 19-gauge needle (Echo Tip®Ultra;Wilson-Cook,Winston Salem, NC, USA). She was discharged on the following day. She returned to our hospital 1 week later due to persistent upper abdominal pain and low-grade fever. Her vital signs were: blood pressure, 105/ 66 mmHg; regular pulse, 96 b.p.m. and temperature of 38°C. The patient’s abdomen was soft, flat, and slightly distended with mild tenderness in the upper area. The laboratory findings were as follows: obvious inflammation with white blood cells (WBC) 13 500/mL and C-reactive protein (CRP) 28 mg/ dL. Multi-detector row computed tomography (MDCT) revealed diffuse thickening of the gastric wall and air trapped within it (Fig. 1). Upper gastrointestinal endoscopy revealed diffuse erythema, edema and erosions (Fig. 2). EUS also showed diffuse gastric wall thickening, predominantly in the submucosa (Fig. 3). The culture of several biopsy specimens from the mucosal surface revealed a-Streptococcus and PG caused by EUS-FNA was clinically diagnosed. The patient recovered after antibiotic therapy with peperacillin/ tazobactam and she was discharged on hospital day 15. EUS-FNA is a safe procedure with a complication rate of approximately 1% that does not normally require antibiotic prophylaxis. However, the risk of PG must be considered for immunocompromised patients with advanced cancer and preventative antibiotics may be necessary.

Phlegmonous gastritis caused by endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA)

Phlegmonous gastritis is an extremely rare and life-threatening condition. We report the case of a 32-week pregnant women presenting a peritonitis owing to phlegmonous gastritis caused by a group A streptococcus and successfully managed by conservative surgical treatment and antibiotics. Multiple endoscopies with biopsies illustrate progressive and complete gastric recovery.

Phlegmonous gastritis in a 32-week pregnant woman managed by conservative surgical treatment and antibiotics.

Phlegmonous gastritis, or acute suppurative gastritis, is a rare, life-threatening condition which is characterized by purulent necrosis and thickening of the gastric wall. A combination of gastrectomy and antibiotic therapy is an effective treatment. We report a rare case of phlegmonous gastritis occurring after endoscopic mucosal resection. The patient was treated initially with antibiotic therapy but eventually required surgery.

Phlegmonous gastritis after endoscopic mucosal resection.

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Phlegmonous gastritis after endoscopic mucosal resection.