S4466 Esophageal Sarcina ventriculi: A Rare Finding in a Patient With Intractable Hiccups

Introduction: Sarcina ventriculi is a gram-positive, anaerobic coccus with characteristic tetrad morphology. Most commonly found in the stomach, it is associated with delayed gastric emptying, gastric outlet obstruction, and, rarely, gastric perforation. Esophageal involvement is exceedingly rare, with few cases reported. While its pathogenic role remains unclear, S. ventriculi may serve as a marker of gastric stasis. We present a rare case of esophageal Sarcina ventriculi in a patient with months-long intractable hiccups unresponsive to standard therapy. Case Description/Methods: A 66-year-old man with gastroesophageal reflux disease and prior hiatal hernia repair presented with persistent hiccups for over 5 months. Associated symptoms included mild dysphagia and bloating, but hiccups were the predominant concern. He had undergone multiple failed treatments including PPIs, prokinetics, vagal nerve stimulation, and phrenic nerve blocks. Esophagogastroduodenoscopy revealed normal esophageal mucosa with excess secretions. Visualization of the gastric cardia and fundus was limited due to retained food, raising concern for delayed gastric emptying. Biopsies from the mid and distal esophagus showed intraepithelial lymphocytosis and luminal debris containing tetrad-forming gram-positive cocci consistent with Sarcina ventriculi. No eosinophilic esophagitis or H. pylori was seen. He was treated with ciprofloxacin and metronidazole, but symptoms persisted. A gastric emptying study was ordered, and he was referred for G-POEM due to suspected gastroparesis. Discussion: This case demonstrates the rare presence of Sarcina ventriculi in the esophagus, likely reflecting underlying foregut dysmotility rather than active infection. Its detection, despite the absence of mucosal damage and lack of symptom improvement with antibiotics, supports its role as a marker of impaired motility. Clinicians should consider evaluating for dysmotility when Sarcina is identified, particularly in patients with refractory upper GI symptoms or food retention on endoscopy.