A rare case of gastric wall abscess arising after endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic mass
09. April 2018 (online)
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.
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 % . Infectious complications associated with EUS-FNA of solid lesions are infrequent, with an incidence of 0 – 0.6 %  . 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.
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