Combined corrosive esophageal and gastric injuries are not uncommon, especially with acid ingestion injuries.¹ However, the formation of gastrocele is an uncommon consequence of combined esophagogastric corrosive injuries.² Formation of gastrocele occurs in the presence of dual obstructions, i.e., one at the esophageal end and one at the pyloric end. Since there is hardly any healthy mucosa left after corrosive acid injury, the development of gastrocele is very rare after an esophageal bypass surgery in these patients. This case report discusses about two patients who developed gastrocele after colonic pull-up, to find possible presentation and management strategies.

Case 1: A 43-year-old lady underwent a colonic pull up with colojejunostomy and colocolic anastomosis for a combined corrosive esophageal and gastric injury 7 years ago at our institution. She had presented with absolute dysphagia before primary surgery following a brief period of euphagia. Initial endoscopy showed a Zargar grade 3A esophageal injury, while the stomach could not be assessed as the endoscope could not be negotiated further. The barium swallow was suggestive of a long segment stricture involving the mid and lower esophagus with a contracted stomach (Figure 1). The operative findings of index surgery revealed a contracted stomach (type III gastric stricture) along with a corrosive esophageal stricture starting at 18 cm from the incisors. She had a smooth recovery and has been on a full oral diet since then.

Case 2: A 20-year old female with long segment corrosive esophageal stricture status failed endoscopic dilation underwent a colonic pullup with colo-jejunal and colocolic anastomosis 4 months after an accidental corrosive intake esophageal injury. The operative findings of the index surgery were suggestive of a contracted stomach (Type III gastric stricture) with a high corrosive stricture of the esophagus. 8 months following the index surgery, she presented with symptoms of pain in the abdomen, fever, dyspnea on exertion, and recurrent episodes of vomiting. The vomitus contained muco-purulent material without any food particles. On evaluation, she had raised total leukocyte counts (23,600 per microliter) with anemia (hemoglobin = 5.3 gram/dl). A CECT scan of the abdomen revealed a distended stomach with thickened walls suggestive of gastrocele. After optimization of her clinical condition, she was taken up for explorative laparotomy. The operative findings revealed a dilated fundus and body of the stomach with thickened walls filled with purulent, foul-smelling mucopurulent material. She underwent Roux-En-Y gastrojejunostomy, and the postoperative course was uneventful. The patient is doing well after six years of follow-up.

The term “gastrocele” was coined by Chandramohan et al., for gastric mucocele in 2008.² It usually appears early in the disease’s course, during the cicatrization phase of healing. The mean duration of presentation was 110 days after ingestion of the corrosive intake. It is thought to develop as a result of dual obstruction of the stomach due to stricture in the pyloroduodenal region and at the GE junction. The remnant normal mucosa, or the mucosa that has regenerated in the stomach, secretes mucous and gastric juices is thought to be the reason behind the formation of gastrocele. They are usually reported in patients sustaining type 3 A and 3 B corrosive gastric and esophageal injuries.³ The usual presentations of gastrocele include pain and fullness in the upper abdomen, respiratory distress, and intolerance to feeding via feeding jejunostomy. The presentation of a gastrocele post colonic pull up varies from those presenting before definitive surgery. The patients who have undergone colonic pullups may present with mild, dull-aching abdominal pain without any other associated symptoms, fowl-smelling vomiting containing mucopurulent material with severe retching, sepsis, and weight loss. The vomiting may be through the thin streak-like opening that may be present in the strictured esophageal lumen due to enormously increased pressure within the gastrocele. Most of the published literature available on gastrocele has mentioned the development of the same early in the course of the disease.^2,3 However, the duration of the development of gastrocele may vary from months to years, as seen in our case report. A similar late presentation of gastrocele after colon pull up was reported by S. Ghatak et al.⁴ A thorough review of previous history from the patient regarding an euphagic period before the development of complete dysphagia or a demonstration of the passage of a thin streak of barium into a partially contracted stomach (Figure 3), on the other hand, should raise clinical suspicion of a gastrocele. The previous series suggested a barium swallow as a modality to diagnose a gastrocele; however, CECT abdomen with oral contrast is a better modality for greater details. Endoscopy is usually not possible in these patients as they have complete or near-complete strictures of the esophagus, which are not amenable to dilation in most cases. Careful intraoperative assessment of the stomach during esophageal bypass surgery is the key to avoid the formation of gastrocele after a colonic bypass. The presence of a fully or partially contracted, thick-walled stomach precludes the cologastric anastomosis, making a colojejunal anastomosis necessary. Total or partial gastrectomy, though described in the literature for isolated gastric strictures, may not be appropriate in all patients with combined esophagogastric strictures, as it may even add to morbidity in patients with corrosive strictures who are already severely malnourished.^2,5 With the experience of managing more than 100 cases of corrosive esophageal injury, we feel that routine gastrectomy is unnecessary for the patients of combined gastroesophageal strictures, as its incidence is very rare and as it adds to the postoperative complications in an already nutritionally debilitated patient.⁷ However whenever a gastrojejunostomy is considered in patients of gastrocele, athorough inspection of the lumen of the stomach to rule out the possibility of malignancy is a must, especially in patients with delayed presentation, although it is rare.¹

Though the occurrence of a gastrocele is rare, it should be kept in the differential diagnosis of epigastric pain and vomiting in follow-up cases of colonic pullup with colojejunostomy, even with a severely contracted stomach on index surgery. A thorough review of previous records and a barium swallow, along with a CECT abdomen, confirm the diagnosis of a gastrocele. A gastrojejunostomy can be offered to these patients after a thorough intraoperative examination to rule out malignancy.