S5061 Uncommon Culprit: Sarcina ventriculi Causing Gastric Ulceration in a Gastroparetic Patient

Introduction: Sarcina ventriculi is a rare, gram-positive, anaerobic coccus known to thrive in acidic environments. Although often considered a benign commensal organism, its presence has been associated with severe gastrointestinal diseases such as emphysematous gastritis and gastric perforation. Gastroparesis, a chronic motility disorder, provides a favorable environment for the growth of S. ventriculi. We present a case of S. ventriculi identified in a patient with gastroparesis and discuss its clinical significance along with diagnostic and therapeutic considerations. Case Description/Methods: A 77-year-old woman with idiopathic gastroparesis and multiple comorbidities presented with abdominal pain, distention, and nausea. She was given metoclopramide, rifaximin, and prucalopride with no relief. Imaging revealed gastric and colonic distention with early pneumatosis. She was treated with nasogastric decompression which provided improvement and discharged on intranasal metoclopramide. Two weeks later she re-presented with worsening symptoms. Computed tomography (CT) showed a massively distended stomach. She was treated with nasogastric decompression and intravenous metoclopramide. Esophagogastroduodenoscopy (EGD) revealed grade C esophagitis, a non-bleeding gastric ulcer, and erythematous gastric mucosa. Due to symptoms and imaging findings, her pylorus was injected with botulinum injection. Gastric biopsies identified S. ventriculi. She was treated with a 2-week course of metronidazole. At 1 month follow up, her symptoms improved. EGD at the time of follow up showed a healed gastric ulcer and persistent food retention. Discussion: S. ventriculi is increasingly recognized in gastrointestinal pathology with growing evidence that it may be pathogenic. In our case, S. ventriculi was identified during a symptomatic flare of gastroparesis, and the patient’s improvement after metronidazole treatment supports a potential contributory role rather than incidental presence. In our case, the use of botulinum injection is a confounder that could be a reason for symptom improvement. Ultimately, while S.ventriculi may not be pathogenic in all cases, its detection, particularly in patients with gastroparesis should prompt physicians to consider antibiotic therapy and repeat biopsies. Growing recognition of this organism and its potential pathogenicity may hopefully lead to formalized treatment guidelines.