Case report:
A 52-year-old woman, with a history of hypertension, hospitalized in our department of surgery for a 3-month history of epigastric pain and discomfort, and weight loss. She had no fever either respiratory symptoms. Physical examination revealed mild tenderness in the upper of the abdomen, associated with an epigastric palpable and painful mass measuring 4 cm. There is no cervical lymphadenopathy nor hepatosplenomegaly. laboratory data were normal. and there are no abnormalities on a chest Xray
On upper endoscopy showed a submucosal compression or anterior submucosal lesion, erosive anterior gastropathy, and a fistulous orifice located in the bulb. (figure1)
A biopsy of the lesion was performed and concluded to no malignancy and had no evidence of tuberculosis
An abdominal CT scan was performed and showed an exophytic, heterogenous gastric formation with an axial necrotic center measuring 44*24mm, associated with multiple tissue nodules of enhanced infra centimeter size after injection of contrast agent evoking peritoneal carcinosis nodules, and coeliomesenteric lymph nodes, one of which has a necrotic center measuring 9mm in diameter associated with hepatic hilum lymph nodes. (figure2)
Endoscopic ultrasound demonstrated a rounded lesion of about 30*26mm located in the antrum, hypoechogenic, discretely heterogeneous not vascularized, and it is distant from the gastric wall whose 5 layers appear of normal aspect(figure3). and by positioning the probe next to the bulbar fistulous orifice, we found the lesion with a hypoechogenic center corresponding to the necrosis described at the CT with a hypoechoic fistulous path.
The patient was operated on for exploratory laparotomy due to the prediagnosis of suspected gastric cancer. the surgical findings indicated a bulky mass adjacent to the antrum with posterior development invading the transverse mesocolon, associated with multiple adenopathies of the mesentery, the transverse mesocolon, and the greater omentum, organized inflows. (figure 4)
There is a second mass of 3 cm located in the small omentum in contact with the left gastric artery, which is probably voluminous adenopathy(figure 4). the biopsy was sent for frozen section examination that concluded to tuberculous intraperitoneal lymphadenitis, so the operation was terminated, gastrotomy was not performed because of the benign nature of the pathology. The patient was administered anti-tuberculosis treatment and was closely monitored.