Image of the Month
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 14-year-old girl presented with a 2-month history of persistent epigastric pain. Both upper gastrointestinal study and esophagogastroduodenoscopy revealed a deep pouch from the gastric antrum (Fig. 1A–C). Biopsy showed eosinophilic gastritis but normal mucosa of the pouch. Given this unusual endoscopic finding and persistence of symptoms on omeprazole, the patient eventually underwent surgery and was found to have intramural diverticulum with heterotopic pancreatic parenchyma (Fig. 1D).
Although it is more common in adults and is sometimes associated with bleeding, gastric diverticulum is rare in pediatric patients (1). Congenital gastric diverticula are located commonly in the gastroesophageal junction (2), whereas acquired gastric diverticula are usually present near the antrum and are associated with peptic ulcer disease, malignancy, or prior surgery (3,4). The location of diverticulum in our case suggests an acquired etiology, and heterotopic pancreas could theoretically result in gastric wall weakness or traction diverticulum. Some authors recommend surgery to aid in diagnosis, to help alleviate symptoms that are unresponsive to medical treatment, and to prevent potential complications (ie, bleeding or perforation) (2,5). Our patient initially had decreased pain after surgery; however, her pain returned, indicating that it may be related to biopsy-proven eosinophilic gastritis.
1. Simstein NL. Congenital gastric anomalies. Am Surg
2. Rodeberg D, Zaheer S, Moir CR, et al. Gastric diverticulum: a series of four pediatric patients. J Pediatr Gastroenterol Nutr
3. Schweiger F, Noonan J. An unusual case of gastric diverticulosis. Am J Gastroenterol
4. Wolters VM, Nikkels PG, Van Der Zee DC, et al. A gastric diverticulum containing pancreatic tissue and presenting as congenital double pylorus: case report and review of the literature. J Pediatr Gastroenterol Nutr
5. Ciftci AO, Tanyel C, Hicsonmez A. Gastric diverticulum: an uncommon cause of abdominal pain in a 12 year old. J Pediatr Surg