Pazhanivel Mohan MD, Murali Ananthavadivelu MD, Jayanthi ... · Practice CMAJ CMA J•MARCH 23,...

Practice CMAJ CMAJ • MARCH 23, 2010 • 182(5) © 2010 Canadian Medical Association or its licensors E226 A 58-year-old man presented with a one-month history of upper abdominal pain and anorexia. There was no history of dysphagia, vomiting, hematemesis, melena, tiredness or jaundice. His complete blood count, renal function and liver enzyme levels were normal, as were the results of ultrasonography of the abdomen. An upper gastrointestinal endoscopic scan showed a diverticulum in the fundus of the stomach (Figure 1). The pain was reproduced by probing the diverticulum with biopsy forceps as well as by insufflating it with air. The patient’s symptoms improved after four weeks’ therapy with proton pump inhib itors. Discussion Gastric diverticula are uncommon, the rates of detection by endoscopy ranging from 0.01%–0.11%. 1 They usually occur in middle-aged people, with equal distribution among men and women, and can be congenital or acquired. 1,2 Areas of weak- ness caused by splitting of the longitudinal muscle fibres, an absence of peritoneal membrane and perforating arterioles may predispose to the formation of a diverticulum. Gastric diverticula are often single, varying in size from 1 to 3 cm. However, multiple and larger diverticula have also been noted, usually adjacent to the gastroesophageal junction and along the lesser curvature or posterior gastric wall. 2 Gas- tric cardia diverticula may simulate a left adrenal mass; those on the posterior wall could herniate through the dorsal mesen- tery and fuse with the left posterior body wall. 3 Patients with gastric diverticula are often asymptomatic, although they may present with dyspepsia, vomiting and abdominal pain. Complications such as ulceration, perforation, hemorrhage, torsion and malignancy are uncommon. 2,4 The condition is diagnosed incidentally by radiologic or endoscopic examination. There is no specific treatment required for an asymptomatic diverticulum. 2 Surgical resection is recommended when the diverticulum is large, symptomatic or complicated by bleeding, perforation or malignancy. Both open and laparoscopic resection yield good results. Perioperative gastroscopy can help locate the diverticulum in difficult situations. Laparoscopic access to the posterior aspect of the gastric fundus is possible after the gas- trocolic ligament has been divided. 1 Competing interests: None declared. REFERENCES 1. Donkervoort SC, Baak LC, Blaauwgeers JL, et al. Laparoscopic resection of a symptomatic gastric diverticulum: a minimally invasive solution. JSLS 2006;10:525-7. 2. Harford W, Jeyarajah R. Diverticula of the pharynx, esophagus, stomach, and small intestine. In: Feldman M, Friedman L, Brandt L, et al. editors. Sleisenger & Fordtran’s gastrointestinal and liver disease. 8th ed. Philadelphia (PA): Saunders; 2006. p. 465-77. 3. Schwartz AN, Goiney RC, Graney DO. Gastric diverticulum simulating an adrenal mass: CT appearance and embryogenesis. AJR Am J Roentgenol 1986;146:553-4. 4. Gibbons CP, Harvey L. An ulcerated gastric diverticulum — a rare cause of haema t emesis and melaena. Postgrad Med J 1984;60:693-5. Clinical images Gastric diverticulum Pazhanivel Mohan MD, Murali Ananthavadivelu MD, Jayanthi Venkataraman MD From the Department of Gastroenterology, Stanley Medical College, Chennai, India CMAJ 2010. DOI:10.1503/cmaj.090832 DOI:10.1503/cmaj.090832 Figure 1: Upper gastrointestinal endoscopic scan showing a diverticulum (arrow) in the fundus of the stomach. Previously published at www.cmaj.ca

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Transcript of Pazhanivel Mohan MD, Murali Ananthavadivelu MD, Jayanthi ... · Practice CMAJ CMA J•MARCH 23,...

Practice CMAJ

E226

A58-year-old man presented with a one-month historyof upper abdominal pain and anorexia. There was nohistory of dysphagia, vomiting, hematemesis,

melena, tiredness or jaundice. His complete blood count,renal function and liver enzyme levels were normal, as werethe results of ultrasonography of the abdomen. An upper gas-trointestinal endoscopic scan showed a diverticulum in thefundus of the stomach (Figure 1). The pain was reproducedby probing the diverticulum with biopsy forceps as well asby insufflating it with air. The patient’s symptoms improvedafter four weeks’ therapy with proton pump inhib itors.

Discussion

Gastric diverticula are uncommon, the rates of detection byendoscopy ranging from 0.01%–0.11%.1 They usually occur inmiddle-aged people, with equal distribution among men andwomen, and can be congenital or acquired.1,2 Areas of weak-ness caused by splitting of the longitudinal muscle fibres, anabsence of peritoneal membrane and perforating arteriolesmay predispose to the formation of a diverticulum.Gastric diverticula are often single, varying in size from

1 to 3 cm. However, multiple and larger diverticula have alsobeen noted, usually adjacent to the gastroesophageal junctionand along the lesser curvature or posterior gastric wall.2 Gas-tric cardia diverticula may simulate a left adrenal mass; thoseon the posterior wall could herniate through the dorsal mesen-tery and fuse with the left posterior body wall.3

Patients with gastric diverticula are often asymptomatic,although they may present with dyspepsia, vomiting andabdominal pain. Complications such as ulceration, perforation,hemorrhage, torsion and malignancy are uncommon.2,4 Thecondition is diagnosed incidentally by radiologic or endo-scopic examination. There is no specific treatment required foran asymptomatic diverticulum.2

Surgical resection is recommended when the diverticulumis large, symptomatic or complicated by bleeding, perforationor malignancy. Both open and laparoscopic resection yieldgood results. Perioperative gastroscopy can help locate thediverticulum in difficult situations. Laparoscopic access to theposterior aspect of the gastric fundus is possible after the gas-trocolic ligament has been divided.1

Competing interests: None declared.

REFERENCES1. Donkervoort SC, Baak LC, Blaauwgeers JL, et al. Laparoscopic resection of a

symptomatic gastric diverticulum: a minimally invasive solution. JSLS2006;10:525-7.

2. Harford W, Jeyarajah R. Diverticula of the pharynx, esophagus, stomach, andsmall intestine. In: Feldman M, Friedman L, Brandt L, et al. editors. Sleisenger &Fordtran’s gastrointestinal and liver disease. 8th ed. Philadelphia (PA): Saunders;2006. p. 465-77.

3. Schwartz AN, Goiney RC, Graney DO. Gastric diverticulum simulating an adrenalmass: CT appearance and embryogenesis. AJR Am J Roentgenol 1986;146:553-4.

4. Gibbons CP, Harvey L. An ulcerated gastric diverticulum — a rare cause ofhaema temesis and melaena. Postgrad Med J 1984;60:693-5.

Clinical images

Gastric diverticulum

Pazhanivel Mohan MD, Murali Ananthavadivelu MD, Jayanthi Venkataraman MD

From the Department of Gastroenterology, Stanley Medical College,Chennai, India

CMAJ 2010. DOI:10.1503/cmaj.090832DOI:10.1503/cmaj.090832

Figure 1: Upper gastrointestinal endoscopic scan showing adiverticulum (arrow) in the fundus of the stomach.

Previously published at www.cmaj.ca