Not Cancer … but Pyloric Stenosis in a 69-year-old?

Abstract

Idiopathic hypertrophic pyloric stenosis (IHPS) is most commonly reported in infants with rates ranging from 0.25% to 0.8% of all live births. Adult IHPS is rare and only 200 cases have been reported in the literature. We present a patient in her late-sixties with cachexia and severe malnutrition with a gastric mass visualized on CT that initially was concerning for malignancy and was subsequently diagnosed with IHPS. A 69-year-old woman, with limited healthcare exposure, was admitted to the hospital with weight loss, anorexia, fatigue, severe malnutrition (BMI 13.7), severe anemia, elevated inflammatory markers (CRP >200, ESR 76), and hypotension leading to a traumatic fall. She was an active smoker with a 51 pack-year history and consumed 2 alcoholic drinks daily. She denied history of acid reflux and had no known history of H. pylori. Rheumatologic workup was negative. Given lack of medical history and severe cachexia, CT chest and abdomen were obtained as there was concern for malignancy. A right ovarian cyst and cystic lesion in the head of pancreas was initially reported and were subsequently determined to be benign. Due to her continued inability to tolerate oral intake, EGD was performed which revealed gastric stenosis with pinhole opening at the pylorus and no visible ulcerations. Biopsy revealed reactive gastropathy and foveolar hyperplasia without inflammation. Review of CT did show evidence of hypertrophy around the pyloric sphincter. She was endoscopically dilated and was able to advance her diet with careful monitoring for refeeding syndrome. At her three-month follow-up visit, she was tolerating general diet, was slowly gaining weight, and her anemia had resolved. This case demonstrates an uncommon case of adult-onset IHPS causing severe malnutrition and cachexia. Most cases of hypertrophic pyloric stenosis are diagnosed in early infanthood. Initial management often includes nasogastric tube placement to remove gastric contents. Gastrectomy, pyloromyotomy, and pyloroplasty have been recommended for surgical management with laparoscopic pyloroplasty as the preferred intervention due to its favorable safety profile. Dilation is another acceptable treatment option; however has a high recurrence rate of stenosis.Figure: Computed tomography, coronal view of pyloric stenosis in a 69-year-old female.