A 13-year-old boy with a history of high-risk neuroblastoma is seen for progressive abdominal pain. On exam he is mildly distended with tenderness to palpation in both upper quadrants. He is currently febrile and slightly tachycardic. There is no free air on plain radiographs. Subsequent cross-sectional imaging is concerning for pneumogastria (see below). The most likely causative agent for this disease process is

 

[center][/center]

 

 

 

[size=20px]A Entamoeba histolytica

 

B Clostridium difficile

 

C Helicobacter pylori

 

D Escherichia coli

 

E Streptococcus pneumoniae[/size]

B

C

E

Correct answer

E Streptococcus pneumoniae

 

Phlegmonous gastritis is a rare cause of abdominal pain in children. Case reports have shown this disease process in both healthy and immunocompromised patients. Imaging often shows gastric pneumatosis with or without portal venous air. The diagnosis is often made on imaging. If endoscopy is performed it should be done carefully due to the friability of the mucosa. Endoscopic findings show edematous gastric mucosa with a submucosal purulence. The causative agent is most commonly often identified as a Streptococcus species, but multiple organisms may contribute. Little is known about the pathophysiology of this disease process. The initial treatment is broad spectrum antibiotics. In cases with physiologic deterioration, a total gastrectomy may be indicated.