Description:
CASE PRESENTATION:
We present a case of 31years old female who was evaluated for intermittent episodes of nausea, non-bilious vomiting & upper abdominal discomfort for more than one year. Her past medical history was significant for resolved Parotid and Thyroid cancers. Remaining history and review of the systems were unremarkable. Her physical examination was only significant for the pallor. Laboratory data revealed severe iron deficiency anemia. Hemoglobin of 6.2 gm/dl, MCV of 68.4 fl, Ferritin of 8.2 ng/ml, normal prealbumin and stool occult was faintly positive. Other routine laboratory work up was normal.
CT ABDOMEN:
A CT scan of the abdomen revealed folding of the stomach back upon itself at the level of the antrum before sweeping inferiorly towards the right upper quadrant (pylorus region). A target or bull`s eye sign was also obvious. The proximal and second portion of the duodenum was also distended to over 5 cm in diameter.
FL GI Series:
An upper GI series revealed a distorted stomach with multiple nodular filling defects in the antrum and the duodenal bulb and suggestion of gastroduodenal intussusception.
EGD:
EGD revealed numerous small yellowish nodules at the cardia and the gastroesophageal junction. A more then 10cm yellowish polypoidal mass with numerous superficial erosions was noticed occupying the body of the stomach, multiple forceps biopsies were taken and send for the histopathology.
COLONOSCOPY:
A colonoscopy was also performed which also revealed small yellowish nodules throughout the colon, no mass lesion was identified.
HISTOPATHOLOGY:
Stomach biopsy showed fragments of hyperplastic polyps with focal xanthelasma but no helicobacter pylori were identified. Colonic biopsies also revealed xanthelasmas.
FURTHER HOSPITAL COURSE:
This polypoidal mass was thought not to be resectable via endoscopic intervention. A partial gastrectomy with lymph node sampling was then performed. Surgical specimen revealed a 9cm x 7cm x 2cm cluster of multiple polypoidal masses. Histopathology revealed hyperplastic polyps with superficial ulceration and focal xanthelasma, no cancer was found. Patient did well after surgery and discharged home in stable condition.
DISCUSSION:
1. First case of gastroduodenal intussusception was reported by Chiari in 1888.
2. Although proplapse of the gastric mucosa through pylorus can happen more frequently but prolapse of all three layers of the stomach is a rare entity and usually caused by prolapse of a gastric tumor (mostly benign and rarely malignant) resulting in invagination of a portion of the stomach into the duodenum. 1-3
3. Symptoms can be episodic epigastric discomfort, intermittent nausea, vomiting and acute or chronic blood loss.
4. The diagnosis can be made by CT scan of the abdomen, upper gastrointestinal series or direct visualization by upper endoscopy.
5. Typical CT findings are a classic target or bull`s eye appearance of the intussusceptions as seen in our patient.
6. Treatment involves the treating the underlying cause by either endoscopic removal of the endoscopically resectable tumor or by surgical excision in case of unresectable tumor by endoscopy, as was in our patient.
References:
1: Vinces FY, et al: Gastroduodenal intussusception secondary to a gastric lipoma. Can J Gastroenterol. (2005) Feb;19(2):107-8.
2: Crowther KS, et al: Case report: gastroduodenal intussusception of a gastrointestinal stromal tumor. Br J Radiol. (2002) Dec; 75(900):987-9.
3: Lin F, et al: Gastroduodenal intussusception secondary to a gastric lipoma: a case report and review of the literature. Am Surg. (1992) Dec; 58(12):772-4.
Contributed By:
Rana Khan, MD, New York Methodist Hospital, Brooklyn, New York
Won Sohn, MD, New York Methodist Hospital, Brooklyn, New York
