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A Teenager With Acute Abdominal Mass: A Case of Gastro-Gastric Intussusception

Published:September 13, 2022DOI:https://doi.org/10.1016/j.jemermed.2022.09.025
      A previously healthy 17-year-old boy presented to the emergency department with worsening left upper quadrant abdominal pain, a history of nonbloody, nonbilious emesis for 2 days, more recent bloody emesis for 1 day, and an abdominal “mass.” He had eaten dinner as usual 3 days earlier and gone to sleep. He woke up that morning with abdominal pain and felt a “mass” in the left side of his upper abdomen, which he stated would decrease in size by applying pressure. He started vomiting the same day, which initially contained food contents and exacerbated his pain. He was only able to tolerate liquids. On the day of presentation, he noticed bright red blood in his vomit and decided to come to the emergency department. He denied diarrhea, hematochezia, constipation, history of similar episodes, nonsteroidal anti-inflammatory medication use, or trauma. On examination, his initial vitals included a pulse rate of 57 beats/min, blood pressure of 135/86 mm Hg, respiratory rate of 20 breaths/min, and oxygen saturation of 99% on room air. He was tired appearing, with sunken eyes and dry mucus membranes. Abdomen was soft but tender to palpation on the left upper quadrant with a distinct firm mass measuring 6 × 5 cm to the left of midline, along the costal margin. Bowel sounds were normal. He had no hepatosplenomegaly. His initial laboratory studies showed hemoglobin of 16 g/dL, white blood cell count of 11,000/μL, with normal electrolytes, creatinine, and lipase. The initial impression included an acute-onset abdominal mass of unknown origin. Due to the location of the mass in the left upper quadrant, with suspicion of originating in the upper gastrointestinal (GI) tract, an abdominal computed tomography (CT) with intravenous contrast and oral contrast was performed to better visualize the hollow viscera. CT demonstrated a fluid-filled, “U-shaped” mass of 6.8 × 5.4 cm in the stomach, near the gastroesophageal junction of unclear etiology, possibly repressing intussusception of the gastric cardia vs. a cystic mass (Figure 1).
      Figure 1
      Figure 1Telescoping of stomach near the gastroesophageal junction in (A) coronal and (B) sagittal views.

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