Gastric mucosal prolapse: A case of proton‐pump inhibitor nonresponsive dyspepsia

Abstract

Key Clinical Message

Gastric mucosal prolapse (GMP) is a rare clinical syndrome that in patients with hiatal hernias and gastroesophageal reflux disease (GERD) may present with typical findings of abdominal pain and reflux symptoms but prove resistant to medical therapy. Physicians should therefore be aware and consider GMP as a differential in such patients in order to make an accurate diagnosis and provide timely treatment.

CASE REPORT

A 31-year-old obese female patient with a history of asthma presented to the clinic for persistent epigastric abdominal pain, unresponsive to proton-pump inhibitor therapy, and exacerbated after meals and at night when she laid down to sleep. The pain was associated with nocturnal nonproductive cough. Physical examination and laboratory findings were unremarkable. Esophagogastroduodenoscopy (EGD) demonstrated a small hiatal hernia and a near obstructing gastric mucosal prolapse into the esophageal lumen upon coughing (Figure ).

[IMAGE OMITTED. SEE PDF]

QUESTION

What is the diagnosis based on the EGD and how is it managed?

ANSWER

Gastric mucosal prolapsed (GMP) as a dynamic clinical entity where gastric mucosa protrudes into the lumen of the distal esophagus. GMP has an overall incidence rate of 2%-5.5% with 90% male predominance. Mechanisms proposed include relaxation at the gastroesophageal junction, disproportionate redundancy of the gastric mucosa, and retrograde gastric peristalsis. GMP has been reported in patients with history of nonsteroidal anti-inflammatory drug use, alcohol abuse, gastroenteritis, hyperemesis gravidarum, uremia, malignancy, and duodenal ulcers. GMP may present as abdominal pain with reflux symptoms but is unresponsive to medical therapy, due the mechanical component of prolapsing gastric mucosa. GMP is diagnosed at the time of EGD or radiographic imaging such as barium swallow. Surgical intervention with Nissen fundoplication has shown over 90% complete relief of reflux symptoms.

DISCLOSURES

None.

INFORMED CONSENT

Informed consent has been obtained for the publication of this clinical image from the patient.

CONFLICT OF INTEREST

None declared.

AUTHORSHIP

TS and EO: involved in conception and design; TS, EO, and KSY: drafted the article; TS, EO, and VG: critically revised the article for important intellectual content; TS, EO, KSY, and VG: involved in final approval of the article.

References

Shephard HA, Harvey J, Jackson A, Colin‐Jones DG. Recurrent retch‐ ing with gastric mucosal prolapse. A proposed prolapse gastropathy syndrome. Dig Dis Sci. 1984;29:121‐128.

Byfield F, Ligresti R, Green PH, Finegold J, Garcia‐Carrasquillo RJ. Hematemesis due to prolapse gastropathy: an emetogenic injury. Gastrointest Endosc. 1998;48:527‐529.