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Case Report | Volume 3 Issue 3 (July-September, 2013) | Pages 123 - 126

Foregut Duplication Cyst as a Rare Cause of Hematemesis: A Case Report

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1
Associate Professor of Pediatric Surgery, University of Medical Science, Rafsanjan, Iran
2
Medical Student, University of Medical Science, Rafsanjan, Iran
3
Associate Professor of Pathology, University of Medical Science, Rafsanjan, Iran
Under a Creative Commons license
Open Access
Published
Sept. 30, 2013

Abstract

Duplications of the gastrointestinal tract are rare congenital malformations that usually present in the first two years of life with symptoms of poor weight gain and palpable abdominal mass. We report here a case of a 9-year-old boy who was evaluated for massive upper gastrointestinal bleeding. Upper endoscopy revealed a submucosal large mass in fundus of the stomach with a 3-centimeter diameter ulcer. Our provisional diagnosis was gastrointestinal stromal tumor (GIST) which was later revised to gastric duplication cyst. Gastric duplication cyst is misdiagnosed as leiomyoma or GIST endoscopically and it should be considered in the differential diagnosis of gastrointestinal mass in young children.

INTRODUCTION

Duplications of the alimentary tract are rare congenital anomalies [1]. Among alimentary duplication cysts, the gastric duplication cyst (GDC) is an uncommon congenital anomaly and is often lined by gastrointestinal mucosa [1]. It accounts for 2-8% of all gastrointestinal duplications [1]. GDC lined by pseudostratified columnar ciliated epithelium (PCCE) is extremely uncommon, and only 17 cases have been reported so far [1]. They can occur anywhere throughout the gastrointestinal tract [2]. Symptoms and signs can include vomiting, abdominal pain, and a palpable mass; in some cases, symptoms related to its complications may also be present [3]. The etiology has not been well characterized yet [2]. Radiographic studies such as ultrasonography and computerized axial tomography may help in making a preoperative diagnosis but it is usually confirmed by surgery [2]. We report here case of a 9-year-old boy with massive gastrointestinal bleeding with histopathological diagnosis of gastric duplication. Our patient presented with hematemesis and melena whereas the duplication cyst was of non-communicating form. In this article, we report a case of foregut duplication cyst, arising from the stomach, which clinically mimicked leiomyoma.

CASE REPORT

 A previously healthy 9-year-old boy was admitted in our hospital with complaints of hematemesis and melena. He had loose bloody stool for two days and abdominal pain without nausea and vomiting for one day before presentation. Furthermore, he mentioned symptoms of common cold and coryza. He had no me

pressure, pulse rate, respiratory rate and axillary temperature were 70/50, 120, 24, and 37◦C, respectively. On physical examination, we found a 7 x 4 centimeters mobile mass in the epigastric zone. Peripheral pulses were weak and capillary refill was increased (four seconds). On complete blood count, hemoglobin and hematocrit were low (10.6 g/dl and 30.9%, respectively). The coagulation tests revealed no abnormality (platelet count=241×109 per liter, PTT=30 seconds, and PT=12 seconds). Black color of stools was noted and there were many red blood cells on microscopic examination of stool. Other tests, such as electrolytes, were in normal range. After resuscitation and blood transfusion, endoscopy was performed. During endoscopy, a large submucosal mass in the fundus of stomach with a large 3 centimeter in diameter ulcer was noted with a clot in a significant artery in the crater of the ulcer (Figure 1). Primary impressions for this patient were leiomyoma or GIST. The risk of re-bleeding was high and we were not able to perform other imaging in our center. Therefore, without any further investigations, the child underwent laparotomy. In laparotomy, we found a large mass in the gastric fundus. Most of the mass was palpated inside the stomach wall. Fundus of the stomach was explored, the mass was evaluated and it was found as a 7.5 x 4.5 centimeter duplication cyst. Duplication cyst was non-communicating with the stomach and was associated with large ulcer (three centimeters). Because of operative findings, after ligation of the short gastric vessel, patient underwent segmental resection of the stomach. Following which the stomach was repaired in two layers. Pathological examination of the resected specimen revealed a gastric duplication cyst lined by PCCE (Figures 2, 3 and 4). After operation, the patient had one episode of melena and his vital signs remained stable (blood pressure= 90/55, pulse rate=85, respiratory rate=20, and axillary temperature=37◦C). One week after surgery, the patient was doing well.

dical history of weight loss. At admission, patient was pale and appeared to be in hypovolemic shock.