phlegmon is a spreading diffuse inflammatory process associated with the formation of a suppurative exudate or pus .
phlegmonous infection may involve any gastrointestinal tract site , although the stomach is most frequently involved ( 1 ) . however , phlegmonous involvements of the esophagus , small bowel , or colon are rare ( 1 - 3 ) .
therefore , strong suspicion and recognition of this disease is a key to the diagnosis and prompt management of patients with acute symptoms .
however , the role of surgery has been questioned for the diffuse disease form ( 2 ) .
the authors report a rare case of acute diffuse phlegmonous esophagogastritis . in this case , proper radiologic diagnosis with typical chest computed tomography ( ct ) findings ( 4,5 ) enabled appropriate treatment and timely surgical intervention .
a 48-yr - old man presented with left chest pain , abdominal pain , and dyspnea of three days duration .
five days before admission , he had been involved in a minor motorcycle accident , but was asymptomatic for two days .
however , his vital signs were stable ; heart rate 70/min , respiration 37/min , blood pressure 110/80 mmhg , and body temperature 36.8. a physical examination also revealed no remarkable finding with normal bowel sounds and a soft , flat abdomen with no general or rebound tenderness .
laboratory tests revealed ; wbc 3,200/l , c - reactive protein 31.68 mg / dl , and serum glucose 201 mg / dl , and chest radiography on admission showed mediastinal widening and bilateral pleural effusion ( fig .
the patient underwent endoscopy on the admission day to exclude esophageal rupture , and diffuse thickening of mucosal folds with decreased distensibility and an 1 cm sized mucosal ulcer in upper thoracic esophagus were observed with scattered patches of hemorrhage in the gastric mucosa of the body and antrum . on the evening of first hospital day , the patient was became febrile with a body temperature of 39 , and thus , empirical treatment with broad spectrum antibiotics was immediately started under the suspicion of empyema or secondary infection . on the second hospital day ,
the dyspnea worsened and the amount of left pleural effusion increased on chest radiography . left closed thoracostomy was performed with pus drainage . on the forth hospital day ,
a contrast - enhanced chest ct scan was performed and showed diffuse and marked circumferential wall thickening of the entire thoracic esophagus , extending to gastric cardia and associated with diffuse intramural low density and a peripheral enhancing rim ( fig .
a ct diagnosis of acute phlegmonous esophagogastritis was suggested and bilateral open thoracotomies were performed immediately .
pleural fluid analysis revealed exudates and a surgery was decided due to worsening of clinical condition of the patient and radiologic findings . during surgery
, bilateral multiloculated pleural effusions were evacuated through open thoracotomies and the esophagus was freed from adjacent tissue .
the adventitial and muscular layers of the esophagus were intact and no perforation was identified .
several separate esophageal myotomies were performed and the submucosal layer was found to have been filled with thick , cheesy materials , which were removed from the mucosa by scraping .
blood and sputum cultures of the patient and a microbiologic examination of pleural fluid demonstrated klebsiella pneumoniae .
a follow - up chest ct scan performed on the 49th postoperative day showed reduced diffuse esophageal wall thickening and bilateral pleural effusion ( fig . 2c ) .
phlegmonous infection can affect any site of the gastrointestinal tract , although the stomach is most frequently involved ( 1 - 3 ) .
involvements of other sites have been rarely reported , but the simultaneous involvement of esophagus and stomach has only been reported in a very limited number ( 1 , 2 ) .
phlegmonous infection usually involves the submucosa and not the mucosa ( 1 - 3 ) .
diffuse esophagogastric involvement of phlegmonous inflammation was evident in our case by chest ct and during surgery . in its localized form , an area of acute inflammation in submucosa
phlegmonous infection may also present as a mass in the gastric wall ( 6 ) .
the inflammation produced may involve the muscularis mucosa and the serosa , and lead to perforation or even peritonitis ( 1 ) . in its diffuse form
, phlegmonous infection can involve the entire stomach , but it rarely extends beyond the cardia or pylorus ( 6 ) .
reported predisposing factors ( 4 ) include immune suppression , alcoholism , peptic ulcer disease , chronic gastritis or some other gastric mucosal injury , achlorhydria , infection , connective tissue disease , and malignancy .
presumably , these conditions predispose the stomach to infection by eliminating various defense mechanisms , such as , inherent gastric cytoprotection or the bactericidal effect of gastric acid ( 1 , 6 ) .
nevertheless , approximately 50% of reported cases were previously healthy and had no significant anteceding risk factors ( 6 ) .
we consider that uncontrolled diabetes mellitus and a recent history of chest trauma in combination with excessive alcohol consumption played an important role in the development of the disease in our patient .
histopathologically , the submucosa is thickened and infiltrated by neutrophils and plasma cells with intramural hemorrhage , necrosis , and thrombosis of submucosal blood vessels ( 1 ) .
the most common pathogens are streptococcus species , staphylococcus species , escherichia coli , haemophilus influenzae , proteus , and clostridia ( 6 ) .
streptococcus accounts for approximately 70 to 75% of cases , and it is also the organism most commonly associated with death caused by phlegmonous gastritis .
the causative pathogen of phlegmonous infection in our patient is believed to be klebsiella pneumoniae , based on positive culture results on blood , sputum and pleural fluid .
phlegmonous gastritis has rarely been diagnosed before surgery , because it is seldom considered in the differential diagnosis of an acute abdomen ( 3 ) .
other symptoms include nausea , vomiting , hematemesis , hiccups , prostration , and fever ( 6 ) . on the other hand , when the esophagus is involved , odynophagia , dysphagia , and chest pain are the most common symptoms ( 1 ) .
phlegmonous infection is usually diagnosed at surgery or at autopsy ( 3 ) , and because there are no pathognomonic signs or symptoms , phlegmonous gastritis is rarely diagnosed before surgery .
endoscopy of the affected esophagus shows diffuse luminal narrowing with poor distensibility and ulcer - like lesions ( 3 ) .
endoscopic ultrasonography ( eus ) findings in previous case reports were diffuse thickening with hypoechoic lesions in the submucosal layer ( 1 , 6 ) . the endoscopic examination of our patient also revealed similar findings of diffuse mucosal fold thickening , a mucosal ulcer in the upper thoracic esophagus , and scattered hemorrhagic patches in gastric mucosa . the reported ct findings of acute phlegmonous esophagitis or gastritis include diffuse esophageal and stomach wall thickening with circumferential intramural low attenuation surrounded by a peripheral enhancing rim .
the intramural low attenuation represents severe inflammation and abscess localized to the submucosa and muscularis layer ( 4 , 5 ) . within the thickened wall ,
contrast - enhanced chest ct in our patient showed findings typical of acute phlegmonous inflammation with simultaneous esophageal and stomach involvement .
the radiographic differential diagnoses included a dissecting intramural hematoma and tubular duplication of esophagus and emphysematous esophagitis or gastritis ( 5 , 7 ) .
however , the clinical symptom of a dissecting intramural hematoma is chest pain with no evidence of infection or inflammation , and patients with tubular duplication are likely to have no symptoms or signs .
the overall mortality of phlegmonous gastritis in a review of 36 reported cases was 42% , and the mortality rates of the 10 patients that underwent surgical resection as compared with the 26 patients treated conservatively were 20% ( 2/10 ) and 50% ( 13/26 ) , respectively ( 6 ) . during the last 50 yr , some reports have described patients with phlegmonous gastritis successfully treated with medical therapy alone .
overall , the mortality rate for patients with medially treated localized disease was 17% , whereas that for diffuse disease was 60% .
thus , antibiotic therapy and surgical drainage are effective treatments for acute phlegmonous esophagitis depending on the clinical situation ( 1 , 3 , 8) . in cases of phlegmonous esophagogastritis ,
protracted conservative treatment result in surgical resection due to the possibilities of esophageal necrosis , esophageal stricture , gastric mucosal atrophy , and complicated peritonitis ( 1 , 8 , 9 ) .
our patient was initially treated with broad spectrum antibiotics and left closed thoracostomy with empyema drainage .
however , surgical intervention was decided upon due to a worsening of his condition , the duration of his clinical symptoms , and radiographic findings , which included a proper ct diagnosis of acute phlegmonous esophagogastritis .
we consider that combined medical treatment and timely surgical intervention played an important role in the cure achieved in our patient , who experienced no major post - operative complications . in conclusion , although acute phlegmonous esophagogastritis is rare and a preoperative diagnosis is difficult , awareness of this disease entity and prompt diagnosis based on typical chest ct findings are major key factors to successful treatment .
 acute phlegmonous infection of the gastrointestinal tract is characterized by purulent inflammation of the submucosa and muscular layer with sparing of the mucosa . 
 the authors report a rare case of acute diffuse phlegmonous esophagogastritis , which was well diagnosed based on the typical chest computed tomographic ( ct ) findings and was successfully treated . a 48-yr - old man presented with left chest pain and dyspnea for three days . 
 chest radiograph on admission showed mediastinal widening and bilateral pleural effusion . 
 the patient became febrile and the amount of left pleural effusion is increased on follow - up chest radiograph . 
 left closed thoracostomy was performed with pus drainage . 
 a ct diagnosis of acute phlegmonous esophagogastritis was suggested and a surgery was decided due to worsening of clinical condition of the patient and radiologic findings . 
 esophageal myotomies were performed and the submucosal layer was filled with thick , cheesy materials . 
 the patient was successfully discharged with no postoperative complication . 