torus hyperplasia is a very rare condition also known as focal pyloric hypertrophy ( 1 ) .
this lesion is caused by a circular muscle hypertrophy affecting the lesser curvature near the pylorus .
pathogenesis of the lesion is unclear , some considering it as a persistence of infantile pyloric hypertrophy to adulthood , others noting that it develops within a few weeks in adult ( 1 , 2 ) .
some have speculated that the lesion results from chronic gastritis or from repeated spastic contractions of the area secondary to visceral - visceral reflexes that could be established as a result of local irritation stimulating afferent fibers and starting a reflex arc involving efferents that locally innervate the circular pyloric musculature ( 1 , 3 ) . in summary ,
focal hypertrophic stenosis of the pyloric antrum in adult is classified as primary or secondary types ; 1 ) primary type being an idiopathic torus hyperplasia uncertain of origin , and 2 ) secondary type from a result of muscular thickening due to inflammation , ulceration , or carcinoma ( 4 ) . after the first report on 1946 , torus hyperplasia has been reported as a rare disease ( 5 ) .
although there are some typical findings ( i.e. , recognizable radiologically by narrowing and enlongation of the pyloric cancal and endoscopically by appearances resembling those of the cervix so called characteristic pyloric " cervix sign " ) in this benign disease ( 6 , 7 ) , it is difficult to confirm without resection .
moreover , it is hard to predict the prevalence of the disease because of its ' rarity ( 3 ) .
herein , we report a 56-yr - old man who was diagnosed as torus hyperplasia with appendiceal mucocele after visiting our hospital because of abdominal discomfort . to the best of our knowledge ,
this is the first case of torus hyperplasia with appendiceal mucocele which is found incidentally .
a 56-yr - old man with a history of hypertension presented with abdominal discomfort for one month .
he reported no bowel habit change , nausea , vomiting , or fever , but complained of anal pain .
he had a family history since his father died of advanced gastric cancer . on arrival ,
his blood pressure was 128/87 mmhg , heart rate 80 beats / min , respiratory rate was 20/min , and body temperature was 36.0. the physical examination revealed no abnormalities except rectal examination .
his abdomen was soft and non - tender with normal bowel sound . on rectal examination ,
upper gastrointestinal endoscopy showed a 1.0 cm sized irregular submucosal lesion proximal to the pylorus to the distal antrum on the lesser curvature .
central erosion was noticed on the surface of the lesion due to previous biopsy ( fig .
1 ) . cushion sign revealed negative finding , and biopsy revealed no significant abnormality . on colonoscopy examination which was performed on the same day with upper gastrointestinal endoscopy ,
histological section revealed marked hypertrophy of the distal circular pyloric musculature without an evidence of neoplasia ( fig .
the present case revealed marked hypertrophy of the distal circular pyloric musculature on histological finding , and was diagnosed as torus hyperplasia after the resection . it was consistent with adult idiopathic hypertrophic pyloric stenosis , a benign disease resulting from hypertrophy of the circular fibers of the pyloric canal of unknown etiology . since the patient had no predisposing factors for the development of secondary pyloric stenosis , we considered this lesion as congenital in origin .
although the endoscopic finding revealed typical cervix sign , we were not able to differentiate from true neoplastic lesion before the resection . despite the recent progress in radiology and endoscopy ,
it is very hard to define hypertrophic stenosis in adults ( 8) . on endoscopic finding , torus hyperplasia reveals as submucosal tumor since it arise from circular muscle consisting the pyloric canal which makes it hard to diagnose through endoscopic biopsy ( 6 , 8) .
in addition , it is usually misdiagnosed as carcinoma of the antrum ( 6 ) .
although recent progress of endoscopic ultrasonography and endoscopic resection had been made , it is hard to diagnose only with the aid of endoscopic procedures .
most of these lesions are found incidentally like our case because it cause minimal clinical signs or is asymptomatic . in the absence of the symptoms ,
no clinical treatment is required , and resection is advocated only when stenosis gives rise to symptoms or when a malignancy is suspicious ( 6 , 8) .
although endoscopic dilatation or laparascopic hypertrophy have been reported as alternative treatments ( 9 , 10 ) , distal gastrectomy with gastroduodenostomy is still the main therapy for final diagnosis and treatment .
second , the patient had a fear of gastric cancer since his father died of this malignancy .
third , elective operation for appendiceal mucocele was planned for suspicious malignant potential . in summary , we have experienced a rare disease , tours hyperplasia which was difficult to differentiate from gastric cancer mimicking submucosal tumor .
our experience including typical cervix sign on endoscopic finding would help other endoscopists for their diagnosis .
 primary or idiopathic hypertrophy of the pyloric muscle in adult , so called torus hyperplasia , is an infrequent but an established entity . 
 it is caused by a circular muscle hypertrophy affecting the lesser curvature near the pylorus . 
 since most of the lesions are difficult to differentiate from tumor , distal gastrectomy is usually preformed to rule out most causes of pyloric lesions including neoplastic ones through a pathological study . a 56-yr - old man with a family history of gastric cancer presented with abdominal discomfort of 1 month duration . 
 upper gastrointestinal endoscopy showed a 1.0 cm sized irregular submucosal lesion proximal to the pylorus to the distal antrum on the lesser curvature . on colonoscopy examination , 
 a 1.5 cm sized protruding mass was noticed on the appendiceal orifice . 
 gastrectomy and cecectomy were done , and histological section revealed marked hypertrophy of the distal circular pyloric musculature and an appendiceal mucocele . 
 to the best of our knowledge , this is the first case of torus hyperplasia with appendiceal mucocele which is found incidentally . 
INTRODUCTION
CASE REPORT
DISCUSSION