Upper Gastrointestinal Bleed From a Gastric Duplication Cyst

Introduction: A gastric duplication cyst (GDC) is an uncommon congenital malformation and a rare cause of upper gastrointestinal bleeding. Herein we present a peculiar case of an 83-year-old female with first ever onset of melena found to have a duodenal bulb fistula connecting to a bleeding extraluminal gastric pouch which was ultimately found to be a large GDC. Case Description/Methods: An 83-year-old female with history of bladder cancer treated with laser ablation, gastroesophageal reflux disease (GERD) on omeprazole, and a reported history of a “second stomach” presented to the emergency department with four days of painless, black, and sticky stools with one episode of non-bloody, nonbilious emesis prior to presentation. Presenting vitals were unremarkable, and pertinent laboratory workup demonstrated hemoglobin of 9.4 grams/deciliter, blood urea nitrogen of 35 milligrams/deciliter (mg/dL), and creatinine of 0.8 mg/dL. Esophagogastroduodenoscopy revealed the appearance of a bulge on the greater curvature of the stomach, and a duodenal bulb fistula was found connected to an actively bleeding extraluminal gastric pouch. The pouch could not be fully intubated endoscopically. Computed tomography angiography abdomen/pelvis displayed a possible gastric variant or duplication with a 2.9 centimeter enhancing mass in the proximal region without active extravasation of blood. She continued on intravenous pantoprazole and had one additional episode of melena but remained stable. She underwent partial gastrectomy, duodenal resection, Roux-en-Y gastrojejunostomy, and cholecystectomy without complications. Pathology showed a gastric duplication cyst lined with benign oxyntic mucosa. She was discharged. (Figure) Discussion: Gastrointestinal (GI) duplication cysts are found throughout the GI tract. They may or may not communicate with the GI lumen. Gastric mucosa is present in 50% of GI duplication cysts; they may remain asymptomatic but complications include ulceration, perforation, fistula formulation, and in rare cases gastrointestinal bleeding. Our patient went 83 years without GI bleed or other significant sequelae from the presence of a large GDC, highlighting the variable and unpredictable clinical course of this rare congenital abnormality.Figure 1.: FigureA: Endoscopic view of duodenal bulb fistula connecting to extraluminal gastric pouch lined with gastric mucosa. FigureB: Resected gastric extraluminal pouch post surgical intervention.