Case Presentation: 16-month-old boy with developmental delay, anal atresia, lipomyelomeningocele, and tethered cord syndrome transferred to a tertiary care center for recurrent postprandial blood-streaked emesis and failure to thrive. His past surgical history was remarkable for anorectoplasty. On admission to the outside hospital, his laboratory values were consistent with dehydration, hemoconcentration & hypokalemia. Stool occult blood was positive. An abdominal ultrasound was unremarkable. An abdominal x-ray showed a large amount of colonic stools. He was treated with intravenous fluids & laxatives. Despite multiple bowel movements, the patient’s emesis did not subside. On day 3 of the hospital stay, he was transferred to a tertiary care center for pediatric GI evaluation. At our hospital, his abdomen remained soft, non-tender & non-distended. However, his episodes of postprandial emesis persisted. An X-ray abdomen showed a prominent gas-filled stomach. An upper GI series later revealed delayed gastric emptying with gastroesophageal reflux. Given no symptom improvement, an upper GI endoscopy was eventually performed. It revealed a subepithelial mass measuring 32mm x 30mm in the pre-pyloric region [Fig. 1a]. An endoscopic ultrasound was performed with imaging features consistent with a gastric duplication cyst [Fig. 1b]. Aspiration of the cyst showed thin & amber-colored fluid. Pathology report resulted with foveolar type of epithelium tissue. For definitive management, the patient underwent laparoscopic converted to open resection of a gastric duplication cyst. A repeat upper GI series revealed no obstruction and appropriate gastric emptying. His postoperative course was uncomplicated. The patient resumed oral feeds without difficulty. On postoperative day 7, he was discharged home.

Discussion: Duplication cysts of the gastrointestinal tract are rare congenital disorders of the pediatric population. The incidence is 1:4,500 births, with a slight male predominance. They occur as malformation of embryonic origin involving any segment of the digestive tract from the oral cavity to the large colon. Duplication cysts of the stomach are less common and account for 4-9% of all GI duplication cysts. Association between other birth anomalies such as spinal cord defects, cardiac and urogenital anomalies have been cited. Duplication cyst of the stomach is an infrequent cause of gastric outlet obstruction in children. Acute onset of symptoms can be precipitated by their mass effect. Clinical manifestations are non-specific and can range from postprandial emesis, epigastric fullness, abdominal pain, weight loss, & failure to thrive. Diagnostic accuracy of gastric duplication cysts can be challenging on initial imaging such as ultrasound, CT, or MRI. Endoscopic Ultrasound [EUS] is the modality of choice for diagnostic confirmation. Surgery is often necessary to avoid complications.

Conclusions: Duplication cysts of the stomach can have varied presentations as a rare congenital malformation. Gastric duplication cysts should be suspected in the differential diagnosis of persistent symptoms of emesis in children when initial evaluation remains inconclusive. Endoscopic ultrasound is often necessary for diagnosis accuracy after initial imaging. They are surgically managed with resection.

IMAGE 1: Figure 1a: polypoid subepithelial mass measuring 32mm x 30mm in the antrum at the pre-pyloric region.

IMAGE 2: Figure 1b: Endoscopic ultrasound (EUS) imaging of the lesion seen in figure 1a showing anechoic structure with a multi-layered wall. Aspiration of the lesion revealed thin & amber-colored fluid.