S3064 A Pill-Filled Gastric Diverticulum: An Unusual Cause of Acute Abdominal Pain

Abstract

INTRODUCTION: Gastric diverticula (GD) are rare with an incidence of 0.01–2.6%. While often asymptomatic and incidentally discovered, they may result in abdominal discomfort. We present a case of a pill-filled GD resulting in severe epigastric pain. CASE DESCRIPTION/METHODS: A 60-year-old male presented to the ED secondary to sudden onset of severe epigastric pain preceded by 2 days of moderate epigastric pain and nausea. He denied vomiting or change in bowel habits. His medical history was significant for coronary artery disease and ulcerative colitis in remission on mesalamine. He was hemodynamically stable. Initial labs were unrevealing. Liver function tests and serum lipase were within normal limits. EKG was normal sinus rhythm without ischemic changes, and troponins were negative. He was initiated on proton pump inhibitor (PPI) therapy, analgesia and hyoscyamine without relief. Ultrasound of the right upper quadrant was nonrevealing. CT abdomen revealed a posterior gastric diverticulum containing medication tablets. Due to refractory pain, the patient underwent EGD which confirmed a posterior gastric diverticulum, approximately 2–3 cm in size containing pills and undigested food. In total, 8 pills resembling mesalamine were removed from the diverticulum. Following EGD, the patient reported complete resolution of his abdominal discomfort. Diverticular distention due to pill impaction was suspected to be the etiology of his symptoms. He was discharged home in good health on a PPI with plans for outpatient surgical evaluation. DISCUSSION: GD may result in upper abdominal discomfort (18–30%), dyspepsia, nausea, and halitosis. Pain associated with GD is thought to be secondary to diverticular distention. Thus, diverticula with a wide neck are less symptomatic due to reduced trapping of undigested food. Diverticular retention of food may result in increased gastric acid secretion and resultant diverticulitis. Inflammation may lead to ulceration and, in rare cases, hemorrhage or perforation. Management of GD is determined by size and symptom burden. Diverticula smaller than 4 cm may be managed conservatively with antacid therapy. However, surgical intervention is pursued if associated with refractory symptoms, hemorrhage, perforation or size greater than 4 cm. Both laparoscopic and endoscopic resection have proven to be safe and efficacious. Given its rarity, a high index of suspicion is required for prompt diagnosis. Therefore, we encourage clinician awareness.Figure 1.: Coronal abdominal CT revealing a posterior gastric diverticulum filled with medication tablets.Figure 2.: EGD confirming a posterior gastric diverticulum with the neck measuring approximately 2 cm. Found to filled with 8 pills and undigested food.