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Home , Gastritis, Pancreatic pseudocyst, Pancreatitis

Indium- 111 WBC Detection of Emphysematous in

Vincent Caruana, Lawrence C. Swayne,and John S. Salaki

Departments ofDiagnostic Radiology and Medicine, Morristown Memorial Hospital, Morristown, New Jersey;and Diagnostic Radiology, CollegeofPhysicians and Surgeons, Columbia University, New York, New York

a catheter tunnel . A focus of increased activity was We present a case of emphysematous gastritis initially identified in the pelvis, compatible with infection of the peri detected with 1111noxine-labeled white cell scintig toneal dialysis catheter. In addition, the scan demonstrated raphy and subsequently confirmed by computed tomog increasedradionuclideactivity in the pancreatic bed and a raphy. Early aggressive and supportive therapy broad curvilinearband of increased activity with a sharply resultedin a successfulclinicaloutcome. demarcated outer margin and a less distinct inner margin, J NucI Med 1990; 31:112—114 suggesting localization within a hollow viscus, such as the . A prior upper gastrointestinal series, demonstrating findings compatible with chronic uremic gastropathy, is shown for comparison in Figure 2. A computed tomographic (CT) scan of the (Fig. 3A and B) confirmed the presence mphysematous gastritis is a rare entity, with a of intramural gas in the posterior gastric wall and revealed a recent literature review reporting only 31 casesto date fluid collection in the tail of the with gas in the (1). Ofthe hollow viscera, the stomach is the least often pancreatic bed. reportedsite of intramural gas(2). Patientsare invari Gastroscopy with biopsy was performed and demonstrated ably toxic and there is an associated 60—80%mortality extensiveinflammationand necrosisof the posterior gastric (1). We report an early case ofemphysematous gastritis, wall, compatible with emphysematous gastritis. Gram stain of which was initially detected with indium-l 11- (‘‘‘In) thebiopsyspecimenrevealedmixedgram-negativeorganisms. labeled white blood cells and successfully treated with The patient was started on an empiric regimen of gentamicin and the peritoneal dialysis catheter was removed and hemo aggressive antibiotic therapy. dialysis initiated. Following a 6-wk course of gentamicin, , and supportive therapy, the patient sur CASE REPORT vived despite several complications including: congestive heart A 54-yr-old black female with chronic renal failure on failure, uremic pericarditis, pneumonia with exudative effu peritoneal dialysis was admitted with of unknown sions, and abdominal wound dehiscence. Serial CT scans etiology. Three months prior to admission, she had presented during the convalescent period demonstrated a gradual de with and an infected in the lesser crease of the intramural air and follow-up showed sac which had been treated via an elective percutaneous marked resolution of the . transgastric drainage procedure (3,4). Physical examination during the current admission revealed a febrile (39.2°C)obese DISCUSSION female with epigastric tenderness without guarding or re Historically, gas within the gastric wall has been bound. Pertinent admission laboratory data revealed a sed rate of 26 mm/hr, hemoglobin of 6.8/mm3, hematocrit of categorized under two major headings; gastric emphy 21%, of 13,800/mm3, and peritoneal white sema and emphysematous gastritis (1,2). Gastric em blood cell count of 2,295/mm3 (38% neutrophils). Blood physema implies a situation with intramural gastric gas cultures were consistently negative. without associatedgas-forming organisms. Typically, The patient remained febrile, her white blood cell count the intramural gas is linearly oriented, without gastric increased to 37,800/mm3, and a culture ofthe peritoneal fluid wall thickening. Etiologies for gastric emphysema in grew Torulopsis glabrate which was treated with i.v. ampho dude: instrumentation, trauma, obstruction, and pri tericin B. Subsequently, an [‘‘‘Injoxine-labeledautologous mary pulmonary disease (2,5,6). Emphysematous or white blood cell scan (Fig. lÀand B) was ordered to rule out phlegmonous gastritis defines pathology caused by gas forming . The stomach often appears irregular ReCeivedMay16,1989;revisionacceptedSept.11, 1989. Forreprintscontact:LawrenceC.Swayne,MD,DiagnosticRadklogy, and mottled with gastric wall thickening, although this MorristownMemor@HOSpftaJ,100 MadiSOnAve.,Morristown,NJ 07960. appearance is variable (5, 7). Frequently there is a his

112 The Journal of Nuclear Medicine •Vol. 31 •No. 1 •January1990 @ @.! •@

@ A B

FIGURE1 Anterior (A)and posterior (B) views from an “Inwhite blood cellscandemonstrateactivity in the gastricwall (arrowheads) infenorly,the pancreaticbed (arrows) superiorly and poste riorly,and the peritonealdialysiscatheter site inthe pelvis.

tory of a prior insult such as abuse, gastritis, gastricinfarction, and trauma (1,6,7).A caseof emphy sematous gastritis in association with pancreatitis and renal failure, similar to our patient, has been previously reported (8). Common organisms include: Escherichia coli, Clostridium welchii, and Staphylococcus aureus (2). The entire may separate as a ne

FIGURE2 Anterior view from a prior upper gastrointestinalser@sdarn ‘4 onstrating marked gastric dilatation with retainedfood parti des, compatiblewith chronicuremicgastropathy.

crotic cast, invariably causing cicatricial scarring in @. survivors (5). The treatment is aggressive antibiotic t@$ therapy and vigorous supportive measures with naso gastric suction, intravenous fluids, and . Sur gery in the acute situation is recommended only in cases ofperforation (1,2). In our case, the most likely etiology was extension of R L gas-forming organisms along the catheter-induced gas tropancreatic fistula. The diagnosis was initially sug B gested by an ‘‘‘Inwhite blood cell scan which demon strated an inflammatory process in the gastric wall with apparent diffusion of the radionuclide activity toward the gastric lumen. Computed tomography clearly con firmed the presence of intramural gastric gas and gram negative organisms were subsequently cultured from endoscopic biopsies. Computed tomographic demon stration of intramural gastric gas has been described (1). Unfortunately, since gastric wall thickening is van 1' able in emphysematous gastritis (5, 7), its absence on Cr scansdoesnot excludethe diagnosis.Previous R studies have shown a high sensitivity and specificity of ‘‘‘In leuckocyte scanning for the detection and localiza tion ofinflammatory bowel disease (9,10). The present FIGURE3 case suggests that scintigraphy may be particularly help CT scans of the abdomen (A—B)demonstrate gas withinthe posteriorgastric wall (arrowheads)and inflammedpancreatic ful in these patients in distinguishing gastric emphy bed (arrows). sema from emphysematous gastritis.

Emphysematous Gastritis in Pancreatitis •Caruana et al 113 REFERENCES 6. Udassin R, Aviad I, Vinograd I, Nissan S. Isolated emphyse matous gastritis in an infant. Gastrointest Radiol l984;9: 1. de Lange EE, Switsky VS. Swanson 5, Shaffer HA Jr. Com 9—12. puted tomography of emphysematous gastritis. J Comput 7. WillifordME, Foster WLJr, Halvorsen RA, Thompson WM. AssistTomogr l986;lO:l39—l4l. Emphysematous gastritissecondary to disseminated strongly 2. Kussin SZ, Henry C, Nauarro C, Stenson W, Clam DJ. Gas loidiasis.GastrointestRadiol1982;7:123—126. within the wall ofthe stomach: report ofa case and review of 8. Bloodworth LL, Stevens PE, Bury RF, Arm JP. Emphyse the literature. Dig Dis Sci l982;27:949—954. matous gastritis after acute pancreatitis. GUT 1987;28: 3. Bernardino ME, Amerson JR. Percutaneous gastrocystos 900—902. tomy: A new approach to drainage. 9. Saverymuttu SH, Peters AM, Hodgson HJ, Chadwick VS, Am JRoentgenoll984;l43:l096—1097. Lavender JP. Indium-l 11 autologous leukocyte scanning: 4. Nunez D Jr, Yrizarry JM, Russell E, et al. Transhepatic comparison with radiology for imaging the colon in inflam drainage of pancreatic fluid collections. Am J Roentgenol matoryboweldisease.BrMedJ 1982;285:255—257. 1985;l45:815—818. 10. Stein DT, Gray GM, Gregory PB, Anderson M, Goodwin 5. Tuck JS, Boobis LH. Case report: interstitial emphysema of DA, McDougall IR. Location and activity of ulcerative and the stomach due to perforated . Clin Radiol Chron'scolitisbyindium-l11leukocytescan.Gastroenterol l987;38:315—3l7. ogy 1983;84:388—393.

114 The Journal of NuclearMedicine•Vol.31 •No. 1 •January1990