Gastric diverticulum: a rare incidental finding during computed tomography

A gastric diverticulum is a rare finding in which the wall of the stomach forms an abnormal sac-like projection. Gastric diverticula can be problematic causing symptoms including but not limited to chronic gastroesophageal reflux, abdominal pain, and bloating. When a gastric diverticulum becomes symptomatic, removal is indicated. In specific cases, laparoscopic gastric diverticula resection can be completed with concurrent bariatric surgery. We report the perioperative approach used in a 34-year-old obese woman with a confirmed symptomatic gastric diverticulum undergoing a gastric diverticulum resection with a concurrent laparoscopic sleeve gastrectomy.

Received: 13 January 2009 / Accepted: 14 May 2009 © Association of Surgeons of India 2010 Indian J Surg (March–April 2010) 72:162 DOI: 10.1007/s12262-010-0038-zK. Ray General Surgery Unit, Worthing Hospital, Worthing, West Sussex, BN11 2DH, UK 1. Bhattacharya K. (2005) Gastric diverticulum - ‘Double pylo-E-mail: ray_kausik2003@yahoo.co.in

INTRODUCTION: A double pylorus channel can be congenital or acquired. Acquired double pylorus is thought to be the result of a gastric or duodenal ulcer forming a fistula between the prepyloric antrum and the duodenal bulb. Although it is a rare endoscopic finding, seen in only 0.001%–0.4% of upper gastrointestinal endoscopies1, when acquired, it signifies peptic ulcer disease (PUD) which needs risk factor modification and treatment. CASE DESCRIPTION/METHODS: A 50-year-old man with alcohol use disorder, newly diagnosed alcoholic cirrhosis and recent NSAID use presented with confusion, melena and dark emesis. His physical exam was notable for hypotension (BP 86/55 mmHg), somnolence, confusion and positive asterixis. Laboratory values were remarkable for hemoglobin of 5 g/dL, BUN of 48 mmol/L, platelets of 271 × 109/L and INR of 2. Management included fluid resuscitation, blood transfusion, proton pump inhibitor and octreotide drip. Once hemodynamically stabilized, an upper endoscopy was performed revealing blood in the gastric body, two antral ulcers with visible vessels, but no endoscopic stigmata of liver disease. Adjacent to the pylorus, a slit-like channel connecting the prepyloric antrum to the duodenal bulb was noted and traversed with the endoscope. Helicobacter pylori work up revealed a positive serum antibody. Patient did well post-procedure and received Helicobacter pylori eradication treatment and counseling on alcohol cessation and NSAID avoidance. DISCUSSION: In contrast to congenital double pylorus which is an incidental finding, patients with acquired double pylorus often present with symptoms of PUD. In this case, likely culprits included NSAIDs and Helicobacter pylori. It should be distinguished from other similar appearing endoscopic findings such as gastric diverticulum, as risk factors for PUD need to be investigated in patients with an acquired double pylorus. While treatment with acid suppression and Helicobacter pylori eradication should be pursued, the fistula tract often persists despite treatment2. Endoscopic recognition and familiarity are key to ensure appropriate risk modification, treatment and prevention of endoscopic complications with side-viewing scopes.

Laparoscopic resection of a large proximal gastric diverticulum

Diverticulae are uncommonly encountered in the stomach. They can be congenital or acquired- the latter variety being the less frequent of the two. This article details one such rare case from Lagos, Nigeria and discusses certain aspects of its clinical and endoscopic presentation. We present a 59-year old with a background history of non-steroidal anti-inflammatory drugs abuse presented with hematemesis and melena and was in hemorrhagic shock. After stabilization, the gastroscopy findings were of a gastric diverticulum (GD) in the anterior prepyloric wall. There was a Forrest IIb ulcer in the GD’s wall with surrounding erythema and edema. The patient was successfully managed medically and conservatively and with good long term results.

88 year female with medical history of hypertension, type 2 diabetes mellitus, hyperlipidemia, osteoarthritis, gastroesophageal reflux disease and a vague history of peptic ulcer disease (PUD) presented to emergency department with 2 episodes of black stool and increasing fatigue over the past 3 days. She also reported using ibuprofen regularly for osteoarthritic related symptoms. Physical exam and basic laboratory investigations were also normal with the exception of hemoglobin, which was 7g/dL. Esophagogastroduodenoscopy (EGD) demonstrated a large non-bleeding ulcer (15mm in largest dimension) in the antrum. Notably, there was also a second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus (see Fig. 1 and Fig. 2). Double pylorus is a rare endoscopic finding, found in 0.001% to 0.4% of EGD. It is characterized by two openings between the distal stomach and the duodenal bulb. It can be classified as congenital or acquired based on etiology. Congenital double pylorus is usually found in association with other congenital anomalies like heterotopic pancreatic tissue, pancreatic divisum or gastric duplication. The acquired double pylorus (ADP) is usually associated with PUD and results from a prepyloric ulcer or duodenal bulb ulcer eroding into the duodenum or stomach creating a fistulous opening. Additionally, the use of NSAIDS, corticosteroids and persistent H. pylori infection can affect the healing of ulcers and can lead to ADP. Diagnosis is made by endoscopy or occasionally by radiography with the lesser curvature of stomach being the most common location of these fistulous openings. Double pylorus should be differentiated from a gastric diverticulum during endoscopy and can also be mistaken with a large mucosal fold, tumor or polyp during evaluation with upper gastrointestinal series. Treatment of double pylorus consists of promotion of mucosal healing with proton pump inhibitor and less commonly H2 blockers, avoidance of NSAIDS/corticosteroids, and treatment of H. pylori infection. The majority of fistulas do not close (or may only partially close), however endoscopic division of the bridging tissue with a sphinterotome should be considered for patients presenting with gastric outlet obstruction. Surgical intervention is an option for patients with obstruction refractory to endoscopic treatment or the presence of other complications such as perforation or refractory bleeding.Figure: Second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus.Figure: Second luminal opening between the antrum and duodenal bulb adjacent to the ulcer consistent with a double pylorus.

Gastric diverticula (GD) are the rarest of the gastrointestinal diverticula and are characterized by protrusions of the stomach wall, that can either be congenital or acquired. Despite the fact that the majority of GD are asymptomatic and are detected inadvertently during endoscopy or gastrointestinal (GI) series studies, they might present with a variety of symptoms, including abdominal pain, vomiting, and weight loss. In mild symptomatic instances, GD is treated conservatively with antacids, but surgical excision is indicated for refractory gastric diverticula with persistent symptoms or complications. We represent an incidental finding of asymptomatic gastric diverticulum through endoscopy for a 12-year-oldSaudi male who presented after foreign body ingestion.

Asymptomatic gastric diverticulum as incidental radiographic finding after surgery for strangulated inguinal hernia: Report of a case

Gastric Diverticulum as an Incidental Finding in a 16-year-old Patient

Gastric diverticulum: incidental finding in preoperative study.

Divertículo gástrico congénito como hallazgo casual en paciente de 16 años

A case of gastric diverticulum arising in a patient who had previously undergone anterior lesser curve seromyotomy for chronic duodenal ulcer disease is reported. The endoscopic appearance of this lesion is described and the potential mechanisms of causation are reviewed. The clinical relevance of this rare finding is examined with emphasis on the need for an index of awareness of this abnormality on the part of endoscopists and in particular, on the risks of injudicious biopsy of such a diverticulum.

Incidental Finding of Phytobezoars within Gastric Diverticulum: Diagnosis and Treatment

Neuroendocrine tumors are a rare finding in the gallbladder. The incidence of this entity in the gallbladder is roughly 1.13 cases per 100,000 in the US, with a steady increase in the last decade. Gallbladder neuroendocrine tumors are generally asymptomatic; the majority of cases have been reported as incidental findings in specimens, resected due to secondary symptomatology, such as chronic cholecystitis. Treatment strategies are limited, in part due to the often advanced stage in which this disease presents. Furthermore, there is a restricted utility of diagnostic tools for early detection; these factors contribute to the poor prognosis of this disease process. We describe a case of a gallbladder carcinoid tumor, incidentally found in a 78-year-old male patient who presented to the emergency room complaining of chronic intermittent right upper quadrant pain, accompanied by nausea and vomiting. A positive murphy sign was elicited on physical examination, which was otherwise unremarkable. An abdominal ultrasound showed an otherwise normal-appearing gallbladder except for a "floating polyp" with no suspicious radiologic features. A diagnosis of chronic cholecystitis was presumed, and the patient was taken to the operative room for laparoscopic cholecystectomy. Microscopic evaluation of the gallbladder specimen yielded a diagnosis of a well-differentiated neuroendocrine tumor and complex cholesterol polyps, in a setting of chronic cholecystitis. Neuroendocrine tumors of the gallbladder, a rare entity, are generally asymptomatic, with most cases diagnosed incidentally in gallbladder specimen resected for reasons other than suspected malignancy. Chronic inflammatory processes are seen to be related to the development of metaplasia and possibly the development of tumors of the neuroendocrine lineage. Based on a review of literature, we have found that no specific treatment approach, beyond surgical resection, is in place to manage patients with this condition. Formation of an expert committee to review and discuss guidelines for appropriate clinical monitoring, as well as consideration of a multi-site prospective registry is suggested.

Microfilaria is a major public health problem in tropical countries like India. It is most commonly diagnosed in peripheral blood smears, but detection of microfilaria in FNAC of breast is a rare finding. We are reporting a case of 35 year old female who presented with a painless nodule in left breast. Fine-needle aspiration cytology from the nodule was done, aspiration showed many sheathed motile microfilaria likely Wuchereria bancrofti and the patient was put on anti-filarial treatment with Diethyl carbamazine citrate. In endemic areas, it should be considered as one of the differential diagnoses of a superficial swelling. Despite its high prevalence, filariasis in female breast is a rare finding and careful screening of nodules help in detecting microfilaria even in asymptomatic patients and thus plays a significant role in recognition of the disease and institution of specific treatment.