CASE REPORT A bizarre cause of gastric outlet obstruction S Allopi Fes B Singh Fes J Moodley Fes J Maharaj* FRad Departments of General Surgery and Radiology· University of Natal, Nelson R Mandela School of Medicine, Durban Abstract Gastric outlet obstruction (GOO) is invariably consequent upon intrinsic gastroduodenal pathology. Ingested foreign bodies are rarely considered to be a cause of this condition. We report possibly the first case of GOO caused by metallic foreign bodies occluding the pyloro-duodenal junction. Case report A 40-year-old inmate of a mental sanatorium was referred with epigas- tric pain of 2 weeks' duration, post- prandial vomiting and loss of weight of 6 weeks' duration. Apart from being treated for schizoprenia, there was no history of peptic ulcer disease or other medical ailments. At the sanatorium, he did duty in the work- shop. On examination, the patient was found to be dehydrated. The systemic examination, including abdominal examination, was normal. Biochemical evaluation revealed a mild hypochloraemic metabolic alka- losis, in keeping with GOO. In view of the clinical suspicion of GOO, upper endoscopy was per- formed; this revealed several metallic objects tamponading the pylorus of a capacious stomach. Endoscopic retrieval of these foreign bodies was unsuccessful. Presence of these metal- lic objects was confirmed on plain abdominal X-rays (Fig. I), and their location was confirmed using barium contrast study. At surgery, a contained perfora- tion of the anterior gastric wall was noted; a total of 15 metallic objects Fig. 1. Plain abdominal radiograph demonstrating cluster of metallic foreign objects lodged along pyloro-antral region of a capacious stomach. 39 SA JOURNAL OF RADIOLOGY • October 2001 F/g. 2. Metallic objects (weighing 678 g) retrieved via gastrotomy. ranging in length from 5 to 15 cm were dislodged from the antropyloric region via gastrotomy. These objects weighed a total of 678 g (Fig. 2). The stomach was noted to be grossly dilat- ed. The patient's postoperative recov- ery was uneventful, with satisfactory resolution of his presenting com- plaints. Discussion Chronic peptic ulcer disease is arguably the most likely cause of GOO. Untreated or unsuspected pep- tic ulcer disease accounts for up to 10% of GOO. Other causes include distal gastric cancer and benign stric- tures (of the antropyloro-duodenum) caused by caustic injury, tuberculosis or Crohn's disease. Foreign bodies causing GOO are extremely rare. Possibly the most recognised gastric foreign body is the bezoar, a tightly packed mass of fruit or vegetable matter, hair or other material that forms in the gastro- intestinal tract. Most bezoars form in the stomachs of patients with impaired gastric emptying due to effects of previous gastric surgery or other conditions associated with gas- tric stasis." Bezoars are usually radio- opaque. Given the tendency for these to increase in size, removal is effected CASE REPORT by means of gastrotomy. Eighty per cent of foreign bodies in the upper gastro-intestinal tract occur in paediatric patients, followed by edentulous adults, prisoners and psychiatric patients.' Most objects (80 - 90%) pass spontaneously, but 10 - 20% have to be removed endoscopi- cally, and about 1% require surgery," Objects thicker than 2 cm and longer than 5 cm tend to lodge in the stom- ach.' Long foreign bodies (> 10 cm) tend to lodge in the duode- num, where perforations may devel- op. In addition to causing ulceration, bleeding and perforation, it is con- ceivable that they predispose to GOO, as demonstrated in this patient. The spectrum and size of the for- eign body noted on the imaging stud- ies served as the reason for our early recourse to surgery, rather than an- ticipating the spontaneous passage of these foreign bodies. Recurrent episodes of foreign body ingestion may occur, especially in prisoners, psychiatric patients and patients with peptic strictures. References 1. Goldstein SS, Lewis JH, Rothstein R. Intestinal obstruction due to bezoars. Am J Gastroenterol 1984; 79: 313-318. 2. MIT AM, Mir MA. Phytobezoar after vagotomy with drainage or resection. Br J Surg 1973; 60: 846-849. 3. Webb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastro- enterology 1988; 94: 204-206. 4. Schwartz GE Polsky HS. Ingested foreign bod- ies of the oesophagus. Ann Surg 1985; 51: 173- 178. 5. Perelman H. Toothpick perforation of the gas- trointestinal tract. J Abdom Surg 1962; 4: 51-53. 6. Kock H. Operative endoscopy. Gastrointest Endosc 1977; 24: 65-68. A midline naso- pharyngeal cystic structure Thornwaldt's cyst Ralph Drosten MB BCh, FCRad D/ag Department of Thoracic Imaging Brigham and Women's Hospital Boston, USA Case presentation A 39-year-old woman presented to her doctor complaining of a non-pro- ductive cough. On examination, the clinician identified a non-inflamed cystic lesion in the soft tissues of the posterior nasopharynx, slightly to the right of the midline. Magnetic resonance imaging (MRI) examination of the region of interest confirmed a 12 x 11 mm well- defined cystic lesion in the posterior nasopharynx, slightly to the right of centre. It demonstrated a homoge- neously hyperintense signal on T1- weighted images, fat suppression and STIR sequences (Figs 1, 2 and 3). It had a thin wall and did not infiltrate the adjacent soft tissues. 40 SA JOURNAL OF RADIOLOGY. October 2001 On the basis of these imaging characteristics, the diagnosis of a Thornwaldt's cyst was made. Discussion Thornwaldt's cyst is a midline con- genital pouch or cyst, lined by ecto- derm, within the nasopharyngeal mucosal space. It is present in 4% of autopsy specimens and develops from an ectopic portion of notochordal remnants in the nasopharynx. The peak age of presentation is 15 - 30 years.I Clinical symptoms range from it being completely asymptomatic and an incidental finding, to persistent nasopharyngeal drainage, halitosis and a foul taste in the mouth. The pre- senting cough in our patient's case was presumably secondary to nasopha- ryngeal drainage and irritation. MRI is the imaging modality of choice. Cysts measure from 1 to 30 mm in diameter and have a high signal intensity on Tl and T2-weighted images, probably