www.elsevier.com/locate/jpedsurg

Surgical treatment of a gastric diverticulumin an adolescent

Steven Elliott, Anthony D. Sandler, John J. Meehan, John P. Lawrence*

Division of Pediatric Surgery, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA

0022-3468/$ – see front matter D 2006

doi:10.1016/j.jpedsurg.2006.04.010

* Corresponding author. Tel.: +1 319

E-mail address: john-lawrence@uio

Index words:Gastric diverticulum;

Congenital;

Surgery

Abstract Gastric diverticula are uncommonly seen in childhood. They typically emanate from the

posterior wall of the stomach near the gastroesophageal junction. The authors report on a 15-year-old

adolescent boy who presented with a symptomatic gastric diverticulum that was surgically resected.

Potential pitfalls in diagnosis and treatment are discussed.

D 2006 Elsevier Inc. All rights reserved.

Gastric diverticula are unusual malformations assumed to

be of congenital origin when seen in the pediatric

population. The symptoms associated with a gastric

diverticulum are often vague and nonspecific. We present

a case of an adolescent treated for a gastric diverticulum that

highlights useful diagnostic modalities and an approach

helpful for surgical treatment.

1. Case report

A 15-year-old adolescent boy was referred to our facility

for evaluation of symptoms of left-sided abdominal pres-

sure. The patient had experienced a bfull feelingQ intermit-

tently for about 4 months in the left flank region. He

described the sensation of pressure to be worse with eating

and when lying on his left side. He denied vomiting or any

abnormal bowel function. His past medical history was

remarkable for mononucleosis the previous year. Both his

mother and maternal grandfather had a history of peptic

Elsevier Inc. All rights reserved.

356 1766; fax: +1 319 356 8378.

wa.edu (J.P. Lawrence).

ulcer disease. Physical examination revealed him to be a

well-developed adolescent boy in no acute distress. His

abdominal exam revealed no tenderness, masses, or other

abnormalities. Examination of his left flank and back was

also unremarkable.

The patient’s local physician had instituted empiric

therapy for gastroesophageal reflux with a proton pump

inhibitor several months previously; this failed to relieve his

symptoms. One week before referral, an abdominal ultra-

sound was performed, demonstrating a left suprarenal lesion

(Fig. 1). This was subsequen tly followed by a compu ted

tomography (CT) scan of the abdomen that indicated a

possible gastric diverticulum situated in the left suprarenal

region (Fig. 2). To confirm t he diagnosis, an upper

gastrointestinal (GI) series was obtained, demonstrating a

diverticulum directed posteriorly off the fundus of the

stomach (Fig. 3). Bec ause of the stro ng fami ly hist ory of

ulcer d isease and the possi bility of gastr oesopha geal reflux,

an upper endoscopy was performed. A gastric diverticulum

was visua lized in the fundus of the stomach (Fig. 4); the

gastric mucosa was mildly erythematous and the lower

esophageal sphincter was felt to be somewhat patulous.

The patient was taken to surgery and the operation was

performed through a left subcostal incision. After division

Journal of Pediatric Surgery (2006) 41, 1467–1469

Fig. 1 Longitudinal ultrasound image of the left upper quadrant

demonstrating spleen anteriorly and hypoechoic lesion (in cursors)

superior to left kidney. ig. 3 Lateral view of the upper GI, showing pooling of contrast

diverticulum posteriorly, just below the gastroesophageal

nction.

S. Elliott et al.1468

of the triangular ligament, the left lobe of the liver was

reflected medially, exposing the gastric fundus. Several

short gastric branches were divided and the fundus of the

stomach was mobilized, exposing its posterior surface. A 5-

cm diverticulum was readily visualized and excised with the

resultant defect closed in 2 layers. The patient was

discharged to home tolerating a regular diet on the fourth

postoperative day.

Pathology of the resected specimen showed gastric

mucosa with patchy aggregates of chronic inflammation,

without evidence of heterotopic tissue. The patient’s

antireflux medications were discontinued, and he remains

symptom free at follow-up 1 year later.

2. Discussion

Gastric diverticula are an uncommon form of diverticular

disease of the GI tract, accounting for only 3% of all

Fig. 2 Computed tomography scan of the abdomen showing the

location of diverticulum, but without filling by oral contrast.

Fin

ju

diverticu li [1]. The report ed incidence of gastr ic diver ticula

is 0.04% o n upper GI exams, an d they are found in 0.02% of

autopsies [ 2] . Large di ve rticula may be diff icult t o

distingu ish from a comm unicating gastric du plication [1].

Two types of gastric diverticula are recognized, congen-

ital and acquired. Congenital diverticula are more common,

co mprising around 70% of a ll gastric diver ticula [3].

Typically, they are located on the posterior wall of the

stomach just below the gastroesophageal junction and may

contain ectopic pancreatic tissue. In contrast, acquired

gastric diverticula are pseudodiverticula (lacking muscular

layers) usual ly found near the gastr ic antru m [3]. They are

often associated with other conditions such as gastric

malignancy, peptic ulcer disease, pancreatitis, or prior

surge ry, and are typi cally seen in adu lts [4].

Fig. 4 Retroflexed view on upper endoscopy demonstrating the

endoscope passing through the gastroesophageal junction anteri-

orly and the neck of the diverticulum (arrow) posteriorly.

Surgical treatment of a gastric diverticulum in an adolescent 1469

Patients with gastric diverticula may remain asymptom-

atic throughout life. When symptoms do arise, they most

commonly are upper abdominal pain, nausea, and emesis

[3]. Occasiona lly, patients with gastr ic d iverticula can have

dramatic presentations related to massive bleeding or

perforation. Not unexpectedly, given the posterior location,

physical exam in most children with this disorder is

unremarkable.

The ability to definitively diagnose a gastric diverticulum

can be difficult. Ultrasound or CT scans are commonly the

first studi es radiographi cally performed to evalua te abdom -

inal symptoms in children; either can suggest the diagnosis

of a gastric diverticulum, but may not be specific. Confusion

with adrenal masses, splenic abnormalities, or pancreatic tail

lesions may occur [5]. Ora lly adminis tered contr ast shoul d

be given to facilitate diagnosing gastric diverticula during

CT scanning. More certain diagnosis is often made by upper

endoscopy or an upper GI series, although both modalities

can sti ll miss the lesi on if it has a narrow neck [3]. To

optimize yield, a right anterior oblique view should be used

in an upper GI seri es [3,6]. Uppe r endosco py can rule out

associated pathology and may be able to reproduce

symptom s with distention of the diverticu lum [6].

Surgical resection is the recommended treatment for

symptomatic gastric diverticula. The standard approach is to

open the gastrocolic omentum to visualize the posterior

gastric wal l [3,6]. Difficulty is encount ered in locat ing

known diverticula through this technique, and anterior

gastrostomy to identify the neck of the lesion is reported

[6]. Alternativel y, we would propose that gi ven the

propensity for gastric diverticula to be located near the

gastroesophageal junction, superior mobilization of the

fundus (as might be performed for a fundoplication) gives

a more direct approach to the anticipated location of these

lesions. Laparoscopic resection is also a viable surgical

modalit y for treatmen t [7].

References

[1] Simstein N. Congenital gastric anomalies. Am Surg 1986;52(5):264-8.

[2] Palmer ED. Gastric diverticula. Surg Obstet Gynecol 1951;92:417 -28.

[3] Rodeberg DA, Zaheer S, Moir CR, et al. Gastric diverticulum: a

series of four pediatric patients. J Pediatr Gastroenterol Nutr 2002;

34(5):564-7.

[4] Eras P, Berenbaum S. Gastric diverticula: congenital and acquired. Am

J Gastreoenterol 1972;57:120-32.

[5] Chasse E, Buggenhout A, Zalcman M, et al. Gastric diverticulum

simulating a left adrenal tumor. Surgery 2003;133(4):447 -8.

[6] Anaise D, Brand DL, Smith NL, et al. Pitfalls in diagnosis and

treatment of a symptomatic gastric diverticulum. Gastrointest Endosc

1984;30(1):28 -30.

[7] Fine A. Laparoscopic resection of a large proximal gastric diverticu-

lum. Gastrointest Endosc 1998;48(1):93 -5.