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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e3181770276
Image of the Month

Submucosal Mass

Carter-Kent, Christine MD; Wyneski, Matthew MD; Muniyappa, Pramodha MD; Atay, Orhan MD; Mahajan, Lori MD

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Department of Pediatric Gastroenterology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA

The authors report no conflicts of interest.

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

A 15-year-old male with Crohn disease presented with nausea, abdominal pain, and a 15-lb weight loss. At upper endoscopy a 1.5-cm nonpulsatile, submucosal lesion was visualized in the fundus following gastric insufflation (Fig. 1). The lesion was somewhat irregular in shape but without erythema or erosion of the overlying mucosa. Upon biopsy, the lesion was firm and nonmobile. Biopsies showed chronic active gastritis with Helicobacter pylori; no other pathological abnormalities were identified. Based on this information, which of the following is the most likely diagnosis? (A) Splenic artery aneurysm, (B) gastric duplication cyst, (C) lipoma, (D) splenic cyst, or (E) gastrointestinal stromal tumor (GIST). The correct answer is D.

Fig. 1
Fig. 1
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Magnetic resonance imaging of the abdomen with contrast was performed using the HASTE sequence. Coronal images showed an exophytic splenic cyst pressing upon the posterolateral aspect of the gastric fundus (Fig. 2). Other imaging options included ultrasonography, computed tomography, and endoscopic ultrasound. Endoscopic ultrasound has a higher sensitivity and specificity for differentiating between submucosal lesions and extrinsic compression compared to upper endoscopy in adults; however, this technology is not often readily available in many pediatric practices (1). Splenic cysts are rare in children. They may be primary (epithelial lining present) or secondary (2). Primary cysts are usually congenital, whereas secondary cysts are caused by chronic parasitic infection or abdominal trauma. Complications include spontaneous rupture, abdominal pain, hypersplenism, or malignancy (3,4). Surgery is indicated if the cyst is >5 cm or if complications arise (4). This is the first report of a splenic cyst in a pediatric patient mimicking a gastric mass at upper endoscopy.

Fig. 2
Fig. 2
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The differential diagnosis of the endoscopic abnormality does include splenic artery aneurysm, gastric duplication cyst, lipoma, and a GIST. Splenic artery aneurysms are the third most common abdominal aneurysm. Suggestive findings at endoscopy include a pulsatile bulge along the posterolateral aspect of the fundus. This should be considered in children with long-standing portal hypertension (>10 years) or pseudoaneurysm in individuals with a history of abdominal trauma (5). Gastric duplication cysts should also be considered, but account for only 7% of all enteric duplication cysts. Most are spherical and located along the greater curvature of the stomach, and they do not communicate with the gastric lumen (6). Lipomas are benign, usually single, slow-growing tumors most commonly located in the colon. Only 5% occur in the stomach. At endoscopy, they are not usually firm, but when compressed with biopsy forceps they have a sponge-like sinking impression (“pillow sign”). GIST lesions are typically firm, multiple in number, and have overlying ulceration or hemorrhage of the mucosa.

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REFERENCES

1. Rosch T, Kapfer B, Will U, et al. Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions: a prospective multicenter study. Scand J Gastroenterol 2002; 37:856–862.

2. Morgenstern L. Nonparasitic splenic cysts: pathogenesis, classification, and treatment. J Am Coll Surg 2002; 194:306–314.

3. Czauderna P, Vajda P, Shaarschmidt K, et al. Nonparasitic splenic cysts in children: a multicenter study. Eur J Pediatr Surg 2006; 16:415–419.

4. Mertens J, Penninckx F, DeWever I. Long-term outcome after surgical treatment of nonparasitic splenic cysts. Surg Endosc 2007; 21:206–208.

5. Evans HM, Sharif K, Brown RM, et al. Fatal and life threatening rupture of splenic artery aneurysms in children with portal hypertension. Pediatr Transplant 2004; 8:192–195.

6. Macpherson RI. Gastrointestinal tract duplications: clinical, pathologic, etiologic and radiologic considerations. Radiographics 1993; 13:1063–1080.

© 2008 Lippincott Williams & Wilkins, Inc.

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