Post written by Yusuke Hashimoto, MD, from the Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan.

This case describes a 68-year-old diabetic woman was referred for evaluation of a pancreatic tail mass (maximum diameter, 3.2 cm). To obtain specimens for histologic examination before neoadjuvant chemotherapy, transgastric EUS-FNA was performed with a 22-gauge needle by 3 passes. The mass was diagnosed as adenocarcinoma, and the patient underwent adjuvant chemotherapy before curative resection.

One month after EUS-FNA, the patient was hospitalized with high-grade fever and upper-abdominal pain. CT view showed a tumor in the tail of the pancreas. Inside the posterior gastric wall is a lesion with a low-density area; the location of the lesion seems to match the route of the EUS-FNA procedure. EUS showed a submucosal mass arising mainly from the second to the fourth layer of the gastric wall. The mass showed heterogeneous hyperechogenicity, suggestive of a gastric wall abscess. Endoscopic drainage by the unroofing technique was performed. First, the top of the mucosa with spilling pus was incised, measuring 2.0 cm, by use of a needle-knife in the pure cut mode, and, subsequently, pus began to flow out. Then, lavage of the submucosal abscess cavity was performed with normal saline solution by use of an ERCP catheter. Finally, a rat-toothed forceps was used to open the incision further to facilitate drainage. No pus was noted thereafter in the abscess cavity. The procedure took only a few minutes. Later, culture of the pus grew Streptococcus intermedius. The patient’s symptoms promptly resolved a few days after the procedure, and she was discharged on day 10. Follow-up CT on day 16 revealed marked shrinkage of the GWA. The patient then underwent curative surgery for pancreatic cancer, which was uneventful and without adverse events.

Although GWA is a rare gastric infectious disease like phlegmonous gastritis, a previous report described a case of severe phlegmonous gastritis arising as an adverse event of EUS-FNA. In terms of harboring risk, the patient was diabetic and undergoing neoadjuvant chemotherapy. In how to treat the situation, EUS-guided abscess drainage is a commonly selected therapeutic option by puncture, fistula dilation, and stent placement. In this case, EUS showed submucosal location of the 44-mm abscess in the stomach. Furthermore, the pus was identified coming from the submucosal abscess. So, considering the location and the procedure easiness, we selected the endoscopic unroofing technique for drainage using needle-knife and rat-toothed forceps. The procedure was successfully performed and 10 minutes long with no indwelling stent placement.

Therapy of abscess is generally opened and drained for surgeons, although the EUS-guided therapeutic procedure is more common in peritoneal abscess. The endoscopic unroofing technique is used for gastric submucosal mass biopsy or ennucleation. In this case, the abscess was located in the submucosal stomach with pus appearing from it.  A needle-knife could reach to cut the submucosal mass on EUS. By identification of the location, we were able to select the easier and simpler technique of unroofing the submucosa. This case highlights the use of an endoscopic therapeutic approach for submucosal abscess of the stomach visualized by EUS and treated by endoscopic unroofing and lavage with a flexible endoscopist’s mind.

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