A rare case of gastric wall abscess arising after endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic mass

A 55-year-old man was admitted to our hospital because of a 7-month history of upper abdominal pain. The magnetic resonance imaging (MRI) scan showed a solid mass occupying the body and tail of the pancreas ([Fig. 1 a]). To make a more definitive diagnosis, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was carried out with a 22-gauge needle (EchoTip Ultra HD; Wilson-Cook Medical Inc., Winston Salem, North Carolina, USA). In total, five passes were completed using a fanning technique. Pathological examination of the collected tissue revealed severe atypical epithelial cells, and adenocarcinoma was suspected ([Fig. 1 b]). Combined with MRI images, we clinically diagnosed pancreatic adenocarcinoma.

Fig. 1 Abscess of the stomach wall associated with endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of a solid pancreatic mass. a Magnetic resonance imaging showed a mass in the pancreatic body (arrow). b The pathological diagnosis was severe dysplastic glands and cells; adenocarcinoma was suspected. c Computed tomography (CT) scan showed a hypoattenuating lesion in the posterior stomach wall (arrow), which occurred 7 days after EUS-FNA. d Gastroscopy showed a submucosal mass in the posterior wall of the stomach body. e White pus flowed out after endoscopic incision with a hook knife. f A second CT scan on the 10th day after endoscopic therapy showed that the abscess had disappeared.

One week later, the patient developed increasing upper abdominal pain with high fever. Laboratory examination showed a white blood cell count of 6020 cells/μL and an elevated C-reactive protein (CRP) level of 182.7 mg/dL. Computed tomography (CT) scan revealed a hypoattenuating mass in the posterior stomach wall ([Fig. 1 c]). The patient was diagnosed with a gastric wall abscess that developed after EUS-FNA. Antibiotic therapy with meropenem was started, but after 3 days the response was poor. Therefore, endoscopic drainage was initiated.

A hook knife (KD-620QR HookKnife; Olympus Corp., Tokyo, Japan) was used to make an incision in the mucosa ([Fig. 1 d, e], [Video 1]). Two days after endoscopic drainage, the abdominal pain and fever disappeared, and the CRP level decreased to normal ranges. A second CT scan on the 10th day after endoscopic therapy showed that the abscess had completely disappeared ([Fig. 1 f]).

Video 1 Endoscopic treatment of a gastric wall abscess. Sufficient drainage of pus was made by exposing the abscess cavity with a hook knife and pressing a transparent cap against the gastric wall.

The main postoperative complications of EUS-FNA include bleeding, perforation, infection, and acute pancreatitis, with a total morbidity of 1.2 % [1]. Infectious complications associated with EUS-FNA of solid lesions are infrequent, with an incidence of 0 – 0.6 % [2] [3]. Abscess of the stomach wall arising from EUS-FNA is extremely rare. From our experience, endoscopic incision and drainage seems to be an efficient treatment for such complication.

Endoscopy_UCTN_Code_CPL_1AL_2AD

Competing interests

None

• References

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• 2 Eloubeidi MA, Tamhane A, Varadarajulu S. et al. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006; 63: 622-629
• 3 Levy MJ, Norton ID, Clain JE. et al. Prospective study of bacteremia and complications with EUS FNA of rectal and perirectal lesions. Clin Gastroenterol Hepatol 2007; 5: 684-689