We report a case of gastric mucocele caused by double corrosive strictures involving the gastric outlet and the distal esophagus resulting in a double blind stomach. Continual accumulation of secretions within the gastric lumen leads to an over distended fluid filled stomach simulating an upper abdominal cystic mass. This has been referred to as gastrocoele in recent medical literature.[1] To the best of our knowledge this is the second report describing this entity.

Case report

A 25-year-old male was brought to the hospital following ingestion of corrosive agent with suicidal intent. He complained of severe burning sensation in the chest and abdomen associated with 2-3 episodes of haematemesis. On examination, patient appeared to be emaciated, mildly dehydrated but was hemodynamically stable. Following immediate supportive measures, an early endoscopy showed marked inflammation and ulceration of the pharynx and pharyngo-oesophageal junction, beyond which the scope could not be negotiated. Subsequent barium swallow performed 5 days later revealed significantly narrowed esophagus with complete obstruction just above the gastro-esophageal junction. A feeding jejunostomy was performed to nourish the patient. He was discharged from the hospital 2 weeks later only to be re-admitted 3 months post discharge with complaints of severe respiratory distress, abdominal pain and a palpable swelling in the upper abdomen. The swelling had gradually grown in size over last 5- 6 weeks. On examination there was a large tender cystic mass palpable in the upper abdomen. An ultrasound examination showed a large unilocular cystic lesion anterior to the pancreas with dependent debris. Plain CT scan confirmed a large cystic lesion insinuating between the liver and spleen located anterior to the pancreas (Figure 1). This was thought to be a pancreatic pseudocyst on first glance. However the pancreas appeared normal with preserved peri-pancreatic fat planes. Serum amylase levels were within the normal range. Review of CT images revealed non-visualization of the stomach. Reformatted coronal images suggested that the cyst morphology was conforming to the shape of an over distended stomach (Figure 2). Decompression gastrostomy was done under fluoroscopic guidance and blood-tinged thick secretions were drained out. On instillation of dilute non-ionic contrast the gastric lumen and rugal folds were well delineated (Figure 3). Patient and table tilt maneuvers failed in opacifying the duodenum or in demonstrating reflux of contrast into the distal esophagus, thus confirming strictures of the pyloric antrum and distal esophagus. Subsequently the patient was taken up for pharyngo-coloplasty. Post-operative recovery was uneventful.

Discussion

Ingestion of corrosive agents can result in significant morbidity and mortality due to oro-pharyngeal and gastroesophageal injuries. Even if the patient survives the acute effects, the reparative response can have devastating sequelae such as esophageal and/or gastric stricture formation.[2]

Frequently encountered in adults where it is often suicidal in intent, corrosive ingestion may be accidental in the pediatric population.[3] The degree and extent of damage depends upon several factors like the amount and concentration of the agent, contact time and amount of food in the stomach at the time of ingestion.[2,3]

Corrosive injury to the gastrointestinal tract has varied presentations ranging from erosions, esophagitis, gastritis to corrosive burns leading to stricture formation, which by far remains the foremost long-term complication. Over 90% of patients with third-degree burns and 15-30% with second degree burns go on to develop strictures.[3] The esophagus and pyloric antrum are the most common sites of stricture formation.[2,3,4,5,6] Very rarely concomitant strictures of the gastroesophageal junction and pyloric antrum are encountered i.e. obstruction of both the gastric inlet as well as outlet. This leads to a double blind stomach which acts as a closed loop. It continues to secrete and accumulate secretions resulting in a giant gastric mucocoele which has been referred to as gastrocoele, in recent medical literature.[1] Similar mucoceles although uncommon have also been reported in the esophagus, colon and rectum caused by a similar mechanism leading to a double blind loop formation.[7,8,9] Gastrocoele presents as a slowly growing lump in the abdomen. The over distended fluid filled stomach may lead to respiratory discomfort or abdominal pain. On clinical examination and on abdominal imaging, gastric mucocoele can be confused with a pancreatic pseudocyst or contained leakage.[1] The acute management is based on stabilizing the vital parameters. This includes pain relief and correcting fluid and electrolyte imbalance. The level and extent of the stricture are evaluated with endoscopy and/or barium study. Endoscopic dilatation of esophageal stricture should be attempted in case of short segment esophageal stricture which has encouraging long term results.[10,11] Multiple strictures, tight or long segment strictures merit esophageal bypass surgery.[12] Antral strictures are managed with either antrectomy / partial gastrectomy or gastrojejunostomy.[13]

References