An unusual cause of gastric submucosal bulge on endoscopy.

A 32-year-old female with no comorbidities, presented to us with a history of upper abdominal discomfort of 3 months duration. There was no history of loss of weight or appetite or ingestion of nonsteroidal anti-inflammatory drugs. There was no relief in her symptoms with proton pump inhibitors. Clinical examination was unremarkable. Laboratory investigation revealed normal hemoglobin, liver, and renal function tests. Ultrasound examination of the abdomen revealed enlarged spleen with altered echotexture. Upper gastrointestinal endoscopy revealed erosions in the stomach and antral biopsy revealed presence of Helicobacter pylori. Furthermore, a submucosal bulge was observed in the fundus of the stomach [Figure 1]. Computed tomography examination of the abdomen revealed enlarged spleen with multiple nonenhancing hypodense lesions in the liver and spleen [Figure 2]. One of these hypodense lesions was causing indentation on the gastric wall [arrow; Figure 2]. Her mantoux test was negative. Endoscopic ultrasound (EUS) revealed presence of multiple anechoic lesions of varying sizes in the spleen [Figure 3]. No vascularity was observed in these lesions on color Doppler. EUS-guided aspiration from one of the large anechoic lesion (measuring 1 cm) yielded serous fluid that was negative for malignant cells, as well as acid-fast bacilli [Figure 4]. The patient was given oral ciprofloxacin for 3 days following the procedure. The hydatid serology was negative. The patient's symptoms resolved after eradication of H. pylori and she is now asymptomatic after 3 months of follow-up.

Figure 1

Submucosal bugle in the fundus of the stomach

Figure 2

Computed tomography: Multiple nonenhancing hypodense lesions in the liver and spleen

Figure 3

Endoscopic ultrasound: Multiple anechoic lesions of varying sizes in the spleen

Figure 4

Endoscopic ultrasound-guided aspiration from anechoic lesion in spleen

Nonparasitic splenic cysts are rare and usually asymptomatic. Their diagnosis is usually made incidentally on cross-sectional imaging and is more commonly found in females.[12] They are usually asymptomatic but sometimes may cause symptoms because of compression of other adjacent organs or rarely rupture. They can be diagnosed and characterized by cross-sectional imaging such as ultrasound, computed tomography, and magnetic resonance imaging. EUS is also a useful investigational modality for diagnosing splenic lesions.[3] Image-guided fluid aspiration is useful for excluding inflammatory and neoplastic causes, as well as relief of symptoms in large cysts. Smaller asymptomatic cysts can be carefully followed-up, but larger symptomatic cysts usually need surgery.