Endoscopy Challenge #2 - Jan '10

7 month old female, born at 29 weeks gestation, presented with 7 days of non bilious emesis and leakage of formula from her gastrostomy site

History

Diagnostic evaluation included upper GI contrast study revealing complete gastric outlet obstruction.

Upper GI endoscopy was performed revealing a hypertrophic pyloric mass protruding from the antrum into the gastric lumen.

A 7 month old female, born at 29 weeks gestation, presented with 7 days of non bilious emesis and leakage of formula from her gastrostomy site. There was no history of fever or diarrhea, and there were no sick contacts. The past medical history was notable for oropharyngeal discoordination necessitating gastrostomy feedings. There was no history of eczema or peripheral eosinophilia.

Her family history was negative for asthma, food allergic disease, and eczema.

On physical exam, pertinent findings included a full, but soft abdomen, which appeared to be tender to palpation without palpable mass. Her gastrostomy site had leakage around the tube from the stoma.

Diagnosis

Histologic evaluation of this region revealed gastric antral type mucosa with increased eosinophils seen deep in the mucosa and submucosa. A diagnosis of eosinophilic gastric outlet obstruction was made and amino acid based formula feedings were initiated through the transpyloric tube. Within 7 days the gastric outlet obstruction resolved and by follow up at 6 weeks the child was tolerating elemental gastric feedings.

Discussion

Eosinophilic gastritis as an etiology of gastric outlet obstruction has been described in infants, children and adults1-5. Attempts at therapy have ranged from hydrolysate formula to corticosteroids and even surgical resection1-5. A history of atopy or peripheral eosinophilia is not necessarily present, thus a high index of suspicion may be needed to avoid unnecessary surgical intervention. Endoscopically, eosinophilic gastric outlet obstruction may have an appearance similar to that of infantile hypertrophic pyloric stenosis6, and pinch biopsies may assist in diagnosis when necessary.

Charina Ramirez, MD
Fellow, University of Texas Southwestern
Children's Medical Center, Dallas

Brad Barth, MD
University of Texas Southwestern
Children's Medical Center, Dallas

References

  1. Hummer-Ehret B, Rohrschneider W, Oleszczuk-Raschke K, et al. Eosinophilic gastroenteritis mimicking idiopathic hypertrophic pyloric stenosis. Pediatr Radiol 1998; 28: 711-713.
  2. Aquino A, Domini M, Rossi C, D'Incecco C, et al. Pyloric stenosis due to eosinophilic gastroenteritis: presentation of two cases in mono-ovular twins. Eur J Pediatr 1999;158: 172-173.
  3. Khan S, Orenstein S. Eosinophilic gastroenteritis masquerading as pyloric stenosis. Clin Pediatr 2000;39:55-57.
  4. Kellermayer R, Tatevian N, Klish W, Shulman R. Steroid responsive gastric outlet obstruction in a child. World J of Gastro 2008; 14(14):2270-2271.
  5. Chaudhary R, Shrivastava R, Mukhopadhyay H, et al. Eosinophilic gastritis-an unusual cause of gastric outlet obstruction. Indian J Gastroenterol 2001;20:110.
  6. Liacouras C, Schreiner M, Bellah R. Endoscopic findings in hypertrophic pyloric stenosis: appearance in classic and evolving disease. Gastrointestinal Endoscopy 1997. 45(5):371-374., Cook-Sather S.