What abnormalities are seen on the barium meal radiograph shown in Figure 1? There is a large pouch in the fundus of the stomach associated with an hiatus hernia. The patient was a 47-year-old man who described upper gastrointestinal symptoms for several years including reflux, heartburn, epigastric fullness and prominent burping. Endoscopy revealed an hiatus hernia with Barrett's esophagus and a large gastric diverticulum. The segment of Barrett's esophagus was ablated by argon plasma coagulation. Because of persisting symptoms despite the use of proton pump inhibitors, laparoscopic Nissen fundoplication was performed with simultaneous excision of the diverticulum. A view of the laparoscopic resection using the Endo-GIA is shown in Figure 2. After surgery, his symptoms resolved and a repeat barium meal radiograph was near-normal.Gastric diverticula are an uncommon form of diverticular disease. Rates of detection vary with the method of detection but range from 0.02% in autopsy studies, 0.04% in barium meal radiographs and 0.01-0.11% at endoscopy. The majority of diverticula (75%) are located near the gastroesophageal junction, usually on the lesser curve or posterior aspect. Typical diverticula are 1-3 cm in diameter but large diverticula as demonstrated below can occur. Small diverticula are usually asymptomatic but large diverticula may aggravate symptoms such as esophageal reflux and burping. Other reported complications are rare but include perforation, bleeding from the margin of the diverticulum and cancer formation within a diverticulum.It is uncertain whether gastric diverticula are congenital or acquired. Most diverticula in the gastrointestinal tract are acquired and form as a result of herniation of the mucosa and submucosa through the muscular wall (false diverticula). However, some gastric diverticula may be congenital as the diverticulum can involve all layers of the gastric wall (true diverticulum). It is not known why gastric diverticula are usually located close to the gastroesophageal junction.
Dieulafoy's lesion was described in 1896 by the French pathologist Georges D. Dieulafoy as a vascular malformation in the stomach. Although usually found in the stomach, the lesion may occur anywhere within the gastrointestinal tract and can cause severe hemorrhage. There is no sex or age predilection. The diagnosis is established endoscopically, and the current therapy of choice is endoscopic hemoclipping. Only rarely is the diagnosis confirmed histologically. We report the case of an elderly female patient who, while hospitalised for a slipped intervertebral disc, presented with lower gastrointestinal bleeding. The source of the bleeding was suspected to be in the right colon by endoscopy. Renewed massive bleeding necessitated surgical treatment with resection of the right hemicolon. The histological work-up of the resected specimen identified a 350-micron large tortuous submucosal artery that had eroded.
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