S5053 Trust Your Gut—Except If It’s Strongyloides

Introduction: Strongyloides stercoralis is an intestinal nematode that typically affects the small bowel and often presents asymptomatically or with mild GI symptoms. In immunocompromised patients, it can lead to serious complications such as hyperinfection syndrome. Gastric involvement is rare, and presentation as gastric outlet obstruction (GOO) is even more uncommon. We present a unique case of Strongyloides-associated GOO in a patient with a history of gastric cancer. Case Description/Methods: A 76-year-old man with history of poorly differentiated signet ring gastric adenocarcinoma (status post robotic subtotal gastrectomy with gastro-jejunal anastomosis) was transferred from an outside hospital for further evaluation of GOO. He presented with a 1-week history of nausea and poor oral intake. Esophagogastroduodenoscopy (EGD) was initially performed at the outside hospital and demonstrated severe stenosis at the gastrojejunal junction (GJ), raising concern for near-complete obstruction, which could not be traversed by a standard or an ultraslim endoscope, prompting transfer for advanced management. The patient underwent a repeat EGD which showed a severely edematous and inflamed GJ anastomosis, and a large volume of retained gastric contents. Biopsies revealed Strongyloides infection despite a negative stool ova and parasite screen. The patient was given 1 dose of ivermectin 9 mg and initiated on total parenteral nutrition (TPN) for 3 weeks. He was discharged on TPN and scheduled for surgical revision of anastomosis. Unfortunately, he passed away from pulmonary complications before surgery. Discussion: Our case highlights a rare presentation for Strongyloides infection as GOO in a post-gastrectomy patient. The patient’s immunosuppressed state from chemotherapy may have predisposed him to this atypical presentation. Differentials for GOO include tumor recurrence, stricture, inflammation, and rarely infection. Our case also highlights the challenges in management, including the inability to traverse the stricture with endoscopes and unsuccessful enteral access, necessitating TPN. Stronglyloides is one of the few parasites capable of autoinfection, with hyperinfection syndrome carrying high mortality in immunosuppressed hosts. Early recognition and treatment are critical.