CASE 11716 Published on 03.04.2014

A pseudo adrenal lesion: Gastric diverticulum on CT and MR imaging

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Ummugulsum Bayraktutan, Mecit Kantarci, Hayri Ogul, Berhan Pirimoglu, Leyla Karaca, Yeşim Kizrak

Ataturk universitesi
25090 Erzurum, Turkey;
Email:akkanrad@hotmail.com
Patient

47 years, female

Categories
Area of Interest Abdomen ; Imaging Technique CT, MR
Clinical History
A 47-year-old female patient had palpitation symptoms for two weeks. She came to our department for investigation of hypertension.
Imaging Findings
Ultrasound showed a left adrenal heterogeneous lesion. On contrast enhanced computed tomography (CT) a low density lesion containing air-fluid level measuring 2x2 cm in diameter was found in the left adrenal region adjacent to the gland [Figure 1, 2]. Magnetic resonance (MR) evaluations revealed a lesion that exhibited high signal intensity on T2 sequences, low signal intensity on T1 sequences, and contained hypointense air in all sequences adjacent to the left adrenal gland [Figure 3-5]. The lesion was attached to the stomach. The lesion was considered to be a gastric diverticulum according to the CT and MR imaging findings. On endoscopy the diagnosis was confirmed.
Discussion
Gastric diverticula are the least common diverticula of the gastrointestinal tract and have been observed in 0.03–0.1% of upper gastrointestinal contrast studies, 0.03–0.3% of autopsies, and 0.01–0.11% of oesophago-gastric-duodenal endoscopy studies [1]. They usually occur in middle-aged people (between 20 and 60 years of age), with equal distribution among men and women [2]. Two types of gastric diverticula have been identified, congenital and acquired. Congenital diverticula are more common, comprising 70–75% of all gastric diverticula [3]. They tend to occur high on the posterior wall of the stomach in the cardia region, approximately 2 cm below the oesophago-gastric junction and 3 cm from the lesser curvature of the stomach [4]. In most of the cases they are solitary diverticula consisting of all layers of the stomach. Rarely, in paediatric patients pancreatic tissue is found inside the diverticula, suggesting their congenital nature. The pathophysiology of the occurrence of these juxtacardiac diverticula has shown an underlying weakness in the gastric wall resulting from the division of the longitudinal smooth muscle fibres in the cardia region of the stomach [5]. Acquired (false) gastric diverticula are pseudodiverticula. They do not contain muscular layers and are associated with other conditions such as gastric malignancy, peptic ulcer disease, pancreatitis or prior surgery. They are most common in adults and usually found near the gastric antrum [6].
Barium studies have been used and helped clinicians to report the first cases in the literature [7]. Their characteristic appearance is a mucosa-lined contrast-filled outpouching with air fluid level in the upright position. On CT they are depicted as an abnormal rounded soft tissue shadow containing air in the left paravertebral region. Confusion with adrenal masses, splenic abnormalities or pancreatic tail lesions has been reported as in our case [8]. The rapidly increasing use of upper gastrointestinal endoscopy has enabled us to directly visualize these deformities and also to rule out associated pathology. Symptomatic diverticula can be treated medically if there is no evidence of severe complications (haemorrhage, perforation, chronic inflammation, ulceration). Surgical treatment is required for such cases [7, 8].
In conclusion, a high clinical index of suspicion is needed to diagnose and effectively manage patients with atypically located gastric diverticulum. This condition atypically present with a long history of vague symptoms such as upper abdominal pain and hypertension.
Differential Diagnosis List
Gastric diverticulum
Adrenal lesion
Meckel\'s diverticulum
Final Diagnosis
Gastric diverticulum
Case information
URL: https://www.eurorad.org/case/11716
DOI: 10.1594/EURORAD/CASE.11716
ISSN: 1563-4086