Endosonographic evaluation of giant gastric folds

Diagnostic Value of EUS-Guided Fine-Needle Aspiration Biopsy for Gastric Linitis Plastica with Negative Endoscopic Biopsy

Due to the tendency of gastric linitis plastica (GLP) to cause extensive submucosal infiltration, a superficial endoscopic biopsy sometimes yields no evidence of malignancy, hindering definite diagnosis. The present study was a single-center retrospective analysis of 54 consecutive patients diagnosed with GLP between 2016 and 2020 to evaluate EUS-guided fine-needle aspiration (EUS-FNA) biopsy outcomes in patients with negative endoscopic biopsy findings. A pathological GLP diagnosis was achieved by endoscopic biopsy in 40 patients (74.1%). EUS-FNA biopsy with a 22-gauge needle was performed in 13 of the remaining 14 patients, and GLP diagnosis was confirmed in 10 patients, with a median of three needle passes. The remaining four patients were laparoscopically diagnosed with GLP. The diagnostic ability of EUS-FNA biopsy for GLP was 76.9%, and EUS-FNA biopsy contributed to GLP diagnosis in 18.5% (10/54) of all cases. None of the 13 patients exhibited EUS-FNA biopsy-related adverse events. Univariable and multivariable analyses revealed an absence of superficial ulcerations as a predictor of false-negative endoscopic biopsy findings in patients with GLP. These results suggest EUS-FNA biopsy as a minimally invasive and safe alternative diagnostic modality for GLP in cases where conventional endoscopic biopsy fails to verify malignancy, although prospective studies with larger cohorts are warranted to confirm these findings.

Borrmann Type 4 Advanced Gastric Cancer: Focus on the Development of Scirrhous Gastric Cancer

Early diagnosis of Borrmann type 4 advanced gastric cancer (AGC) is very important for improving the prognosis of AGC patients. Because there is no definite mass in most cases of Borrmann type 4 AGC, its accurate diagnosis via endoscopy requires an understanding of its pathogenesis and developmental process. Moreover, many people confuse linitis plastica (LP) type gastric cancer (GC), scirrhous GC, and Borrmann type 4 AGC. To distinguish each of these cancers, knowledge of their endoscopic and pathological differences is necessary, especially for LP type GCs in the developmental stage. In conclusion, diagnosis of pre-stage or latent LP type GC before progression to typical LP type GC requires the detection of IIc-like lesions in the fundic gland area. It is also crucial to identify any abnormalities such as sclerosis of the gastric wall and hypertrophy of the mucosal folds during endoscopy.

Use of Endoscopic Ultrasound to Evaluate Large Gastric Folds: Features Predictive of Malignancy

The aim of this study was to investigate with endoscopic ultrasound (EUS) the features of the gastric wall that can be used to predict malignant disease in patients with large gastric folds. We retrospectively reviewed the EUS findings of 65 patients (26 with benign and 39 with malignant disease) with large gastric folds on endoscopy and EUS and analyzed the predictors of malignant disease (e.g., gastric wall thickness, preservation of five-layered structure, thickened layers). Gastric wall thickness (≥9.8 mm), thickened deep layer, thickened muscularis propria and non-preserved wall layer structures were significantly more prevalent in patients with malignant disease on EUS. Among them, gastric wall thickness (≥9.8 mm) (odds ratio = 6.72, 95% confidence interval = 1.23-36.73, p = 0.028) and thickened muscularis propria (odds ratio = 37.14, 95% confidence interval = 7.02-196.49, p < 0.001) were significantly associated with malignant disease. Our data indicate that EUS is a useful tool for assessing large gastric folds and that gastric wall thickness (≥9.8 mm) and thickened muscularis propria are significant features predictive of malignant disease on EUS.

Endoscopic ultrasonographic features of gastric linitis plastica in fifty-five Chinese patients

The objective of this study was to investigate the endosonographic appearance of gastric linitis plastica (GLP) and to study the usefulness of endoscopic ultrasonography (EUS) for the T and N staging of GLP. EUS examinations of 55 patients with histologically proven GLP were retrospectively studied. In all patients, EUS showed that lesions involved at least one-third of the circumference of the stomach. Based on the findings of the EUS, the 55 patients were divided into two groups. There were 32 (58.2%) patients in the first group. EUS of this group showed that the five sonographic layers had disappeared and had been replaced by a hypoechogenic thickening of the gastric wall. There were 23 (41.8%) patients in the second group. EUS of this group showed that the first three sonographic layers were blurred and thickened, and the fourth layer was significantly thickened. The full thickness of the gastric wall was significantly thicker in first than in the second group of patients (P<0.01). The incidence of perigastric lesions was significantly higher in the first than in the second group of patients (P<0.01). Results for the 15 patients following preoperative EUS were compared postoperatively with histopathologic findings for T and N staging. The overall diagnostic accuracy of the T stage was 73.3% and of the N stage was 60.0%. In eight patients, we used EUS to assess a therapeutic response. No response was observed in five patients and a partial response in three. EUS images of GLP are characteristic. EUS is helpful in diagnosing GLP and for assessing the T and N stages.

Role of Endoscopic Ultrasonography in Patients With Thickened Wall Stomach by CT Scan

The usefulness of endoscopic ultrasonography (EUS) in patients who have gastric wall thickening in computed tomography (CT) is not clear. All patients referred for EUS due to thickened gastric folds on CT were included in this study. Esophagogastroduodenoscopy (EGD) followed by EUS was performed on all patients. Twenty-eight patients were enrolled in the study. The mean ± SD age was 50.8 ± 15.9 years, and 60.7% were male. Most patients (78.6%) had symptoms, and 10 patients (35.7%) were ultimately diagnosed with a gastric neoplasm. In all patients with a normal EGD (11 patients), the EUS was normal. Accuracy, specificity, sensitivity, positive predictive value, and negative predictive value of EUS for detecting a lesion in thickened wall stomach on CT were 89.3%, 88.8%, 90.0%, 81.8%, and 94.1%, respectively. In patients with a thickened gastric wall by CT, upper gastrointestinal endoscopy should be done before endoscopic ultrasonography, with ultrasonography reserved for those patients with an abnormal EGD. Endoscopic ultrasonography has good sensitivity for lesion detection in cases with an abnormal endoscopy, and the presence of gastric symptoms increases the likelihood of abnormal EUS.

A Case of H. pylori-associated Granulomatous Gastritis with Hypertrophic Gastropathy

A 46-year-old man had chronic granulomatous gastritis characterized by giant gastric folds with noncaseating epithelioid granulomas including giant cells in the corpus. No definite etiologic factors were detected. Histology and the rapid urease test indicated that H. pylori was present in both the antrum and corpus. The granulomatous gastritis with giant gastric folds improved after H. pylori eradication. This case suggests an association between isolated granulomatous gastritis and H. pylori infection.

Protein-losing gastropathy with hypertrophic gastric folds: endosonographic findings

We present a case of protein-losing gastropathy with hypertrophic gastric folds. A 38-year-old man was hospitalized for severe epigastric pain suggestive of hypoproteinemia. Endoscopic and radiologic examination revealed enlarged gastric folds on the greater curvature of the stomach. Endoscopic sonography revealed marked thickening of the second layer on the greater curvature of the stomach. Endoscopic mucosal resection was performed, and the diagnosis was hypertrophic gastritis. After prednisolone treatment, hypoproteinemia and the enlarged gastric folds of the stomach resolved.

Diagnosis of Helicobacter pylori: invasive and non-invasive tests

Helicobacter pylori infection can be diagnosed by invasive techniques requiring endoscopy and biopsy (e.g. histological examination, culture and rapid urease test) and by non-invasive techniques, such as serology, the urea breath test, urine/blood or detection of H. pylori antigen in stool specimen. Some non-invasive tests, such as the urea breath test and the stool antigen test, detect active infection: these are called 'active tests'. Non-invasive tests (e.g. serology, urine, near-patient tests) are markers of exposure to H. pylori but do not indicate if active infection is ongoing; these are 'passive tests'. Non-invasive test-and-treat strategies are widely recommended in the primary care setting. The choice of appropriate test depends on the pre-test probability of infection, the characteristics of the test being used and its cost-effectiveness.

Endoscopic ultrasonography in patients with large gastric folds at endoscopy and biopsies negative for malignancy: predictors of malignant disease and clinical impact

OBJECTIVES

The aims of the study were to assess in patients with large gastric folds at endoscopy and endoscopic biopsies that tested negative for malignancy: (i) the predictive variables of malignancy in endoscopic ultrasonography (EUS), (ii) the impact of EUS.

METHODS

Patients with this condition evaluated with radial EUS (following the standard study protocol of our Unit in these patients) during a 5-yr period were included. Nine variables were evaluated as possible predictors of malignancy (chi2, t-test, and logistic regression procedure) using pathology results, or a minimum of 2 yr of follow-up as gold standard. Likelihood ratios (LR), pre-EUS, and post-EUS probabilities for the diagnosis of malignancy were used to assess the clinical impact of the technique.

RESULTS

Sixty-one patients were included (40 benign and 21 malignant). Predictive factors of malignancy were as follows: thickened gastric wall, thickened deep layers, impaired gastric distension, loss of the wall structure, and presence of ascites or lymph nodes, whereas the enlargement of superficial layers was a predictor of a benign condition. The enlargement of deep layers, as assessed by EUS was the only independent predictive factor for malignancy. When using this parameter, the pre-EUS probability of malignancy in our series (34%) increased up to 95% when EUS suggested malignancy (positive LR = 45), whereas it decreased to 4.7% when EUS precluded this diagnosis (negative LR = 0.102).

CONCLUSIONS

(i) The enlargement of deep layers is the only independent predictive factor for malignancy in patients with large gastric folds at endoscopy and biopsies testing negative for malignancy and (ii) EUS has a high clinical impact in these patients.

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Giant gastric folds: differential diagnosis at US

PURPOSE

To evaluate ultrasonographic (US) features in the differential diagnosis of giant gastric folds.

MATERIALS AND METHODS

One hundred sixty-five patients with giant gastric folds at transabdominal US examination (five with Ménétrier disease, 24 with anisakiasis, 61 with acute gastric mucosal lesion [AGML], 13 with gastric lymphoma, and 62 with scirrhous carcinoma) were examined. With 3-6-MHz curved and 5-11-MHz linear-array transducers, the authors evaluated gastric wall thickness, wall stratification, main thickened layer, echogenicity, and compressibility of the lesion in each case. The Fisher protected least-significant-difference method was used to compare statistically the thickness of the gastric wall among diseases.

RESULTS

Wall thickness of AGML was significantly (P <.001) less than that of anisakiasis, gastric lymphoma, and scirrhous carcinoma. US findings revealed regular gastric wall thickening of the second or third layer, with preservation of wall stratification in all patients with benign conditions. The fourth layer was thickened only in patients with malignancy. The echogenicity of gastric lymphoma was markedly lower than that of any other condition. Compressibility of scirrhous carcinoma was absent, whereas it was well preserved in all benign conditions.

CONCLUSION

Transabdominal US can depict gastric wall stratification and is a useful noninvasive modality for differential diagnosis of giant gastric folds.

Gastrointestinal endoscopic ultrasonography

Although conventional endoscopy provides excellent visualization of gastrointestinal mucosa, it provides little information about intramural or nearby extramural lesions. The imaging of intraabdominal structures by conventional transabdominal ultrasound is degraded by ultrasound energy attenuation with distance. The provision of an ultrasound probe on a flexible gastrointestinal endoscope, to form an echoendoscope, provides excellent imaging of the gastrointestinal wall and of adjacent extramural structures. During the last two decades, endoscopic ultrasound, using an echoendoscope, has revolutionized the diagnosis and treatment of gastrointestinal diseases that affect the submucosa, deep bowel wall, and adjacent extramural structures. This article reviews the role of endoscopic ultrasound in the diagnosis and treatment of gastrointestinal disease, including standard and promising new applications, as well as standard and emerging new technology.

Interobserver agreement in staging gastric malt lymphoma by EUS

BACKGROUND

EUS is highly accurate for staging gastric lymphoma. Because stage correlates to outcome, interobserver agreement is mandatory. However, previous studies suggest that interobserver agreement might vary according to T-stage. A multicenter evaluation of observer agreement with respect to endosonographic staging of gastric mucosa-associated lymphoid tissue (MALT) lymphoma was therefore conducted.

METHODS

Fifty-four patients were studied; 42 were also evaluated after eradication of Helicobacter pylori infection. EUS was performed at different institutions by 10 experienced endosonographers who collected the best photographs for each examination. Interobserver agreement was estimated with kappa statistics.

RESULTS

Overall interobserver agreement for T-stage was fair, both before and after treatment (kappa = 0.38 and kappa = 0.37, respectively). Overall interobserver agreement for N-stage was substantial before treatment, but only fair after treatment (kappa = 0.63 and kappa = 0.34, respectively). The lowest values of agreement occurred with T1sm (submucosa) and T2 stage lesions.

CONCLUSIONS

Interobserver agreement for staging of gastric MALT lymphoma by EUS is suboptimal before as well as after treatment of H pylori infection. This evidence suggests that gastric EUS may be more difficult technically compared with EUS of other organs. Lack of agreement is crucial because it influences the choice of therapy and assessment of response to treatment. Good interobserver agreement would permit better communication concerning the clinical status of patients, comparison of the results of different studies, and stratification of patients within clinical trials.

Endoscopic ultrasound of the upper gastrointestinal tract

Endoscopic ultrasound (EUS) is an evolving technique used by gastroenterologists to examine lesions that are located either within or adjacent to the walls of the upper gastrointestinal (GI) tract; this topic is relatively unknown to most radiologists. Proper use of this modality is benefited by a cooperative effort between gastroenterologists and radiologists specializing in ultrasound and cross-sectional imaging. This article informs radiologists of the applications of this procedure. Most patients are examined with EUS after a biopsy of a mucosal tumor has been performed. A smaller number are performed to evaluate submucosal masses or when pancreatic disease is suspected but not diagnosed. The examinations can be performed either with dedicated flexible echoendoscopes or with catheter-based probes passed through a conventional endoscope. The exact location of abnormalities associated with the upper GI tract can be observed. Known anatomic landmarks are sought. Abnormalities of structures outside the upper GI tract will occasionally be found during these examinations. The specific layers of the walls of the gut are examined, and the T and N-classification of upper GI tumors can be determined accurately. The performance of an EUS examination requires advanced skills, and in many medical centers, it is the imaging modality of choice to stage cancers, to evaluate submucosal masses, and to investigate both malignant and benign pancreaticobiliary disease. Endoscopic ultrasound is sensitive but not specific, and biopsy is necessary to establish a diagnosis. Therapeutic applications of EUS are evolving. Specialized applications with catheter-based probes are also being developed.

Low-grade MALT lymphoma of the stomach: a review of treatment options

PURPOSE

Low-grade mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach (MLS) is often associated with the presence of Helicobacter pylori (H. pylori) bacteria. Eradication of the infection with antibiotic therapy may result in regression of the lymphoma. But when antibiotic treatment fails to reverse the malignant process or if H. pylori is absent, other treatment options should be considered. Because MLS is often confined to the stomach and regional lymph nodes, it is potentially curable with local therapy. Endoscopy and improved imaging, with endoscopic ultrasound (EUS) and computerized tomography (CT), have reduced the prior dependence on surgery for diagnosis and staging of gastric lymphomas.

METHODS AND RESULTS

This review details the advances in the diagnosis, classification, and imaging of MLS. We also describe the experience that supports the use of radiation therapy as the preferred treatment of MLS in patients who have not responded to antibiotic therapy or have not had evidence for H. pylori infection.

CONCLUSIONS

Radiation therapy for MLS is not only effective and safe, but offers the significant advantage of low morbidity and gastric function preservation.

Endosonography in gastric lymphoma and large gastric folds

To establish a correct preoperative differential diagnosis between gastric lymphoma and cancer is essential but can be difficult as endoscopic biopsies can sometimes provide a low diagnostic yield. By EUS, infiltrative carcinoma tends to show a vertical growth in the gastric wall, while lymphoma tends to show mainly a horizontal extension. EUS provides an accurate staging of gastric lymphoma, showing the exact level of infiltration and the presence of perigastric lymph nodes, thus the physician can obtain an accurate prognosis for each patient and select the best form of treatment accordingly. The response to chemoradiotherapy can also be investigated very accurately by EUS. Large gastric folds are seen in a great number of benign and malignant conditions. Diagnosis represents a clinical challenge because etiology may be extremely varied and standard biopsies are often inconclusive. Different diseases show different levels of infiltration of the gastric wall, thus a characteristic echo-pattern helps for the differential diagnosis. Endosonography, used always in combination with biopsy, allows to rule out malignancies and to select the most appropriate treatment for each patient (medical or surgical).

High-resolution endoluminal sonography in gastroenterology

Endosonography is an imaging method where a high frequency ultrasound probe is inserted blindly or under endoscopic control into a lumen. Examination of the gastrointestinal tract is performed using dedicated echoendoscopes or transendoscopic miniprobes. The gastrointestinal wall, mediastinum, pancreas, bile ducts, retroperitoneum, and other structures surrounding the gastrointestinal tract are target organs for endosonography. A detailed image of pathological processes can thus be obtained. The method can be used both for primary diagnosis of lesions and in follow-up of gastrointestinal diseases. It is accurate in local staging of cancer and in detecting small lesions, which cannot be seen with other imaging modalities. There are some limitations for optimal examination like stenoses or other factors prohibiting a precise position of the ultrasound transducer. The clinical importance of endosonographic examinations must be continuously evaluated on the basis of new technical modalities and changes in therapeutic procedures.

Endoscopic ultrasonography in rectal linitis plastica

BACKGROUND

Rectal linitis plastica (RLP) is a rare tumor with a poor prognosis. RLP can be a primary tumor, secondary to gastric linitis, or a metastatic form of breast or prostate carcinoma. Diagnosis is difficult because of nonspecific clinical and endoscopic findings and frequent negative biopsies (50%). The aim of this study was to evaluate the endosonographic appearance of RLP and to study the usefulness of endoscopic ultrasonography (EUS) in the follow-up of patients with RLP.

METHODS

Twenty-two video-recorded EUS examinations performed in 11 patients with histologically proven RLP were retrospectively studied. Response to conservative treatment was evaluated in three patients with secondary RLP.

RESULTS

In every case of RLP, EUS showed a circumferential thickening of the rectal wall (mean 13 mm); the thickening was mainly seen in the submucosa and the muscularis propria. In nine cases EUS showed signs of locoregional involvement (perirectal fat infiltration [n = 6], ascites [n = 5], lymph nodes [n = 3]) which was not seen by CT. In follow-up evaluations, EUS showed a lack of response to treatment in two patients with RLP secondary to gastric linitis. In the remaining patient with RLP secondary to breast carcinoma, EUS at first showed no response. The chemotherapy protocol was modified, and then improvement became evident at EUS.

CONCLUSIONS

RLP shows typical features of rectal EUS that may assist in the diagnosis of this rare disease. Moreover, EUS can be useful in evaluating the response of this disease to treatment.

Ultrasonography of the human stomach

Improved technology and new systems have expanded the possibilities of using ultrasound in clinical gastroenterology.

METHODS

Conventional real-time ultrasound was applied to the stomach in order to study motor activity and accommodation to meals. The antrum was imaged by various modalities of two- and three-dimensional ultrasonography, while duplex sonography was used for studying transpyloric flow. Miniature ultrasound probes and echo-endoscopes were employed for endoscopic ultrasound

RESULTS

The examinations provided new information about contractions, distension, co-ordination of movements, and flow. Patients with functional dyspepsia were characterized by rapid emptying of the proximal stomach, wide gastric antrum, early commencement of transpyloric flow, and epigastric discomfort following ingestion of a meat soup. Endoscopic ultrasonography exposed detailed images of the gastric wall and adjacent structures of great importance in clinical decision-making.

CONCLUSIONS

The new ultrasound methods have improved our diagnostic capabilities and opened new promising possibilities for further research in the field of motility.