Drainage of gastric intramural abscesses using lumen-opposing metal stents Here are the author's disclosures. Gastric intramural abscesses are rare and usually due to the presence of a foreign body. There are few case reports available in the literature to date highlighting endoscopic management of this rare phenomenon. Modalities previously described include the use of various knives to perform knife fenestration or consideration for pigtail catheter placement to provide drainage. However the use of lumen opposing metal stents or lambs have not previously been demonstrated. We present a case of an 83 year old male with diabetes mellitus and prostate cancer previously treated with chemotherapy which he is no longer receiving due to cure. He presented initially with nausea, vomiting, anorexia, and abdominal pain for which he received a CT of the abdomen. This axial CT abdomen image demonstrates the presence of a large gastric intramural fluid collection located in the antrum with the presence of contained air concerning for abscess. The patient was scheduled for endoscopy to perform endoscopic drainage. Here are the endoscopic methods used during this case. The endoscopic methods demonstrated in this video include use of endoscopic ultrasound, use of fluoroscopy, standard upper endoscopy, and electrocardiogram enhanced lumen opposing metal stent placement. Displayed here is an example of a lumen opposing metal stent which contains a biflanged radial expanding mechanism to secure stent placement after deployment. Upon endoscopic examination a large protrusion from the anterior gastric wall along the distal gastric body and pre-pyloric antrum was visualized. Endoscopic ultrasound was then performed and demonstrated the presence of a 3.1 by 2.8 centimeter fluid collection within the gastric wall. Dense vascularity was noted under examination with color flow Doppler increasing concern for bleeding risk with needle knife fenestration. Aspiration was attempted using a 19 gauge needle, however, no material was obtained. This lowered the impression that placement of the pigtail catheter would provide adequate drainage. Given clear visualization of an overlying muscularis mucosa and deep muscularis propria layer to the intramural collection on EUS, confidence in durable stent placement and low risk for perforation yielded decision to decompress with the lumen opposing metal stent. Following ultrasound confirmation, the electrocautery enhanced lumen opposing metal stent system was then prepared for placement between the gastric abscess and the gastric lumen. Fluoroscopic guidance was used for confirmation of stent placement. This resulted in drainage of purulent material which was aspirated for culture. Next, a wire was placed and subsequently a balloon was used to dilate the lumen opposing metal stent to 7 millimeters to maintain stent positioning and patency. Cultures returned positive for Candida cruciate and Enterococcus faecalis. Despite broad-spectrum antibiotics and endoscopic drainage, however, the patient remained symptomatic and repeat CT of the abdomen demonstrated a persistent adjacent gastric intramural abscess to the previously placed lumen opposing metal stent. This prompted repeat upper endoscopy for additional lumen opposing metal stent placement. Upon repeat endoscopy, a persistent large protrusion with overlying mucosal discoloration was again visualized along the anterior gastric wall. The previously placed lumen opposing metal stent appeared well positioned and no longer was draining purulent material. Endoscopic ultrasound demonstrated a 2.4 by 2.2 centimeter contained intramural collection amid a multi-placement of a second lumen opposing metal stent. This was again performed using electrocautery followed by balloon dilation. Both stents can be visualized here. Contrast was then injected through the new stent which was contained within the newly accessed wall collection without communicating to the previously placed stent. This suggested the presence of a second intramural abscess that was not communicating with the one drained previously. Following decompression, the prior stent was inspected with underlying healthy appearing granulation tissue. Using a rat tooth forceps, the stent was removed. Following removal, biopsies of the tissue bed surrounding the prior stent placement was performed and sent to pathology. Pathology demonstrated inflamed granulation tissue consistent with ulcer bed or edge of abscess as delineated by the arrows. There additionally was evidence of giant cells with polarizable foreign material. This is an uncommon finding in gastrointestinal pathology and represents the presence of a foreign body. The presence of a foreign body was the suspected etiology to the initial mucosal injury and formation of multiple intramural gastric abscesses. The patient de-professed and symptoms improved following the second endoscopy. He was discharged home and repeat endoscopy was scheduled in two weeks for removal of the second stent. The second stent appeared to no longer be draining purulent material and healthy appearing granulation tissue was seen at the tissue bed. A rat tooth forceps was again utilized to grasp the edge of the stent and gentle traction applied for stent removal. This is a rare case describing the formation of two discrete intramural gastric abscesses likely related to the presence of foreign body material. It highlights that deployment of lumen-opposing metal stents serves as an effective option for treatment of gastric intramural abscesses and can serve as an alternative to existing methods. In conclusion, deployment of a lumen-opposing metal stent is a safe and effective method for drainage of gastric intramural abscesses.

gastric intramural abscesses

chemotherapy

endoscopic methods

lumen opposing metal stent

foreign body