X-ray diagnosis of elevated lesions of the stomach

The Diagnosis of Small Gastrointestinal Subepithelial Lesions by Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy

Endoscopic ultrasonography (EUS) has been widely accepted in the diagnosis of all types of tumors, especially pancreatic tumors, lymph nodes, and subepithelial lesions (SELs). One reason is that the examination can provide a detailed observation, with tissue samples being immediately obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Many SELs are detected incidentally during endoscopic examinations without symptoms. Most SELs are mesenchymal tumors originating from the fourth layer, such as gastrointestinal stromal tumors (GISTs), leiomyomas, and schwannomas. GISTs are potentially malignant. Surgical treatment is recommended for localized GISTs of ≥20 mm. However, the indications for the diagnosis and follow-up of GISTs of <20 mm in size are controversial. There are several reports on the rapid progression or metastasis of small GISTs. Therefore, it is important to determine whether a SEL is a GIST or not. The main diagnostic method is EUS-FNA. Recently, endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) using a new biopsy needle has been reported to obtain larger tissue samples. Additionally, various biopsy methods have been reported to have a high diagnostic rate for small GISTs. In local gastric SELs, regardless of the tumor size, EUS can be performed first; then, EUS-FNA/B or various biopsy methods can be used to obtain tissue samples for decision-making in relation to therapy and the follow-up period.

Endoscopic and Endosonographic Features of Histologically Proven Gastric Ectopic Pancreas by Endoscopic Resection

Backgrounds/Aims

Distinguishing gastric ectopic pancreas (GEP) from malignant tumors is relatively difficult. This study evaluated the endosonography findings of pathologically proven GEP.

Methods

Thirty-one patients diagnosed with GEP based on a histopathological analysis from January 2004 to July 2018 were enrolled in this study. All patients underwent EUS and an endoscopic resection.

Results

Seventeen patients were female, and the median age was 41.1 years (range, 14-74). The lesions were localized most commonly in the antrum. The mean size of the GEP was 10.6 mm (range, 7-15). Superficial type lesions, lesions with heterogeneous echogenicity, mixed pattern lesions, and lesions with indistinct borders were commonly observed on EUS. Calcification, anechoic duct-like structures, and thickening of the muscularis propria were observed in some patients. Endoscopic mucosal resection (41.9%) and endoscopic submucosal dissection (58.1%) were performed. The mean procedure time was 22.5 minutes. Complete resection was achieved for 71% of patients. No statistically significant results between the endosonography findings and complete resection rates were obtained. The mean follow-up esophagogastroduodenoscopy duration was 4.5 months. None of the patients presented with residual lesions on subsequent endoscopy.

Conclusions

EUS can help identify the features of GEP. Careful observations of the EUS findings can avoid unnecessary removal of GEP.

Systematic Endoscopic Approach for Diagnosing Gastric Subepithelial Tumors

Subepithelial tumors (SETs) are commonly encountered during upper gastrointestinal endoscopy, especially during national gastric cancer screening programs in Korea. Although the majority of SETs are benign, endoscopists harbor concerns regarding whether a SET is benign or malignant because the diagnosis cannot be established on the basis of routine endoscopic biopsy findings. The differential diagnosis of SETs is important, beginning with meticulous endoscopic examination, including the evaluation of the location, macroscopic shape, color, surface characteristics, mobility, consistency, and size of the tumors. The yield of endoscopic biopsy increases with the use of the bite-on-bite technique for SETs without the rolling or tenting sign, with large openings, and with erosion or ulceration. In this review, a systematic approach for the diagnosis of gastric SETs during conventional endoscopy is introduced.

Direct access endoscopy in a Brazilian public healthcare facility: comparable results with specialist referred endoscopy

BACKGROUND

Direct access endoscopy (DAE) is the procedure performed without the pre-evaluation of the patient by a specialist. It is widely available in many medical services around the world, but there is lack of data about this strategy in the setting of the public health system in Brazil. Therefore, the aim of this study is to compare the main endoscopic findings of upper gastrointestinal endoscopy requested through DAE and by specialists.

METHODS

Longitudinal, retrospective single center study in patients who underwent upper digestive endoscopy in a public healthcare facility at the southern region of the state of Mato Grosso, Brazil, from August 2011 to December 2018. Age, gender, modality of endoscopy request (DAE or endoscopy requested by specialists), and endoscopic findings were analyzed.

RESULTS

A total of 2810 patients were included. Most of them were female 65.23% (1833), mean age was 47.36 years, and 50.71% of the exams (1425) were DAE. Only 4.62% of the exams had normal reports. The most frequent endoscopic findings were gastritis (91.99%), bulboduodenitis (43.59%) and reflux esophagitis (14.76%). Patients who underwent endoscopy requested by specialists were older (50.25 ± 16.57 vs. 44.55 ± 16.31 years, p < .0001) and more frequently men (36.61 vs. 32.98%, p = .0437) in comparison to DAE. However, endoscopic findings were similar in both groups.

CONCLUSION

This study shows that direct access upper endoscopy had comparable results to specialist requested endoscopy in a public healthcare facility in the southern region of the state of Mato Grosso, Brazil.

Hyperplastic polyps arising in autoimmune metaplastic atrophic gastritis patients: is this a distinct clinicopathological entity?

OBJECTIVES

Gastric hyperplastic polyp (GHP) commonly arises in the abnormal surrounding mucosa, including autoimmune metaplastic atrophic gastritis (AMAG). We aimed to compare clinicopathological features in patients with GHPs associated with AMAG with those in patients with GHPs associated with non-AMAG.

PATIENTS AND METHODS

A total of 1170 patients with GHP(s) were enrolled, and their clinical and pathological data were analyzed, retrospectively.

RESULTS

The GHP patients were divided into 181 A-GHP (type A GHP, AMAG-associated GHP) participants, 312 B-GHP (type B GHP, Helicobacter pylori infection-associated GHP) participants, and 677 other GHP participants (non-A-GHP and non-B-GHP) based on pathological status of the surrounding non-polypoid mucosa. The A-GHP patients were older and predominantly female (p < .05). Gastroscopically, A-GHPs showed less distal and more multiple-region distribution in the stomach (p < .001). In addition, the A-GHPs were observed to be usually numerous (55.8%), larger (mean maximum diameter 12.3 mm), and more pedunculated or sub-pedunculated (45.3%) (p < .001). Histopathologically, the intestinal metaplasia, intraepithelial neoplasia, and carcinomatous transformation within GHPs were present in 24.3%, 9.9%, and 2.8% of AMAG patients, respectively, which were significantly higher than those in the B-GHPs and other GHPs (p < .05). However, the differences of intraepithelial neoplasia and adenocarcinoma in surrounding non-polypoid mucosa did not reach statistical significance (p > .05).

CONCLUSIONS

The GHP(s) arising in AMAG patients is a distinct subgroup of GHP(s) and was an important precancerous lesion. The biopsy from surrounding non-polypoid mucosa was essential to evaluate the underlying etiology of the GHPs, and endoscopists should pay attention to these.

Endosonographic Findings and the Natural Course of Chronic Gastric Anisakiasis: A Single-Center Experience

Background

Chronic gastric anisakiasis is a rare, usually asymptomatic, and difficult to diagnose infection incidentally discovered during endoscopy, resembling a subepithelial tumor (SET). Because its endoscopic ultrasonography (EUS) findings are not established, it is occasionally misdiagnosed as gastrointestinal mesenchymal tumors and removed by endoscopic or surgical resection. We aimed to assess the characteristic EUS findings of chronic gastric anisakiasis and the clinical course during follow-up.

Methods

The database of all patients who underwent EUS at Pusan National University Hospital (Busan, Korea) between January 2011 and December 2016 was retrospectively analyzed. A total of 28 SET cases with EUS features suggesting chronic gastric anisakiasis were included in the study. The EUS, histopathologic, and follow-up endoscopic features were analyzed.

Results

On EUS, the lesions were mainly located in the submucosal and/or propria muscle layers. Twenty-seven lesions (27/28, 96%) showed hypoechoic echogenicity, and 22 lesions (22/28, 79%) were heterogeneous. Hyperechoic tubular structures suggesting denaturalized Anisakidae larvae were seen in 22 lesions (22/28, 79%). Endoscopic biopsies revealed significant eosinophil infiltration (≥30 per high-power field) in 12 lesions (12/21, 57%). During the median follow-up period of 9 months (range, 1–55 months), SETs decreased or subsided in 26 lesions (26/28, 93%) with no change in the size of the two lesions (2/28, 7%).

Conclusions

Chronic gastric anisakiasis, although rare, should be included in the differential diagnoses for gastric SETs, especially in regions where raw fish is widely consumed. EUS findings suggesting chronic gastric anisakiasis are heterogeneously hypoechoic lesions with hyperechoic tubular structures, mainly in the submucosal and/or muscularis propria layers. Because chronic gastric anisakiasis decreases or subsides in most cases, follow-up endoscopy 6–12 months later is recommended.

Magnifying endoscopy with narrow-band imaging for gastric heterotopic pancreas

BACKGROUND AND STUDY AIMS

 Heterotopic pancreas is a common subepithelial lesion in the stomach. However, its histological diagnosis is difficult when tissue samples are obtained with a conventional biopsy forceps. This study aimed to describe the magnifying endoscopy with narrow-band imaging (ME-NBI) features of gastric heterotopic pancreas.

PATIENTS AND METHODS

 We retrospectively analyzed a database of all patients who underwent endoscopic ultrasonography (EUS) at Pusan National University Hospital from January 2010 to December 2010. Thirty-six patients with endosonographically diagnosed heterotopic pancreas who underwent ME-NBI and endoscopic ultrasonography (EUS) simultaneously were studied. The ME-NBI features of their lesions were analyzed.

RESULTS

 Thirty lesions were located in the antrum and six in the body. Six lesions (17 %) showed umbilication or central dimpling on the surface, and nine (25 %) had a macroscopic opening on the surface. On ME-NBI, a microscopic opening was identified in 22 (81 %) of 27 lesions wherein a macroscopic opening was not observed during conventional endoscopy. Macroscopic or microscopic opening was observed in 31 lesions (86 %). The frequency of macroscopic or microscopic opening was higher in lesions with anechoic duct-like structures than in lesions without such structures on EUS (91 % [29/32] vs 50 % [2/4], P  = 0.027). Focal loss of microsurface structure and presence of a thickened submucosal vessel were observed in 6 (17 %) and 5 lesions (14 %), respectively.

CONCLUSIONS

The characteristic ME-NBI feature of heterotopic pancreas is presence of a microscopic opening on its surface. This ME-NBI feature is potentially useful for differentiating heterotopic pancreas from other gastric subepithelial tumors.

[Gastric adenocarcinoma arising in giant hyperplastic polyp]

Gastric hyperplastic polyps are usually solitary, their development is supposed to be associated with excessive proliferation of foveolar cells. It is essential to differentiate hyperplastic polyps from other sporadic polyps (adenomatous and fundic gland polyps) and lesions, included in familial polyposis syndromes. The frequency of adenocarcinoma in large gastric hyperplastic polyps (more than 1-2 cm in size) is about 2,1%. This article includes case report of gastric adenocarcinoma arised in large hyperplastic polyp in a 56-year-old patient. On histological examination a well-differentiated adenocarcinoma without invasion in the peduncle was identified. Immunohistochemically cells of adenocarcinoma showed elevated expression of claudin-3, CDX2, p53 and Ki67 compared to hyperplastic glands and dysplastic areas of the polyp. Also focal expression of MUC2 was revealed in adenocarcinoma. Expression of MUC5AC, CD44 and cyclin D1 was less prominent in cancer areas compared to hyperplastic and dysplastic glands. Levels of expression of claudin-1, claudin-4 and β-catenin were equal in adenocarcinoma and hyperplastic structures. Control endoscopic examination with following morphologic examination was performed three months after surgical operation. No signs of tumor growth were identified.

Saving from unnecessary pancreaticoduodenectomy. Brunner's gland hamartoma: Case report on a rare duodenal lesion and exhaustive literature review

INTRODUCTION

Brunner's gland hamartoma (BGH) is an infrequently encountered, benign, polypoid proliferation of Brunner's glands. Usually these lesions are asymptomatic, just only occasionally presenting with duodenal obstruction or bleeding signs and mimicking a tumoral lesion.

CASE PRESENTATION

A 72-year-old male, referred for recurrent vomiting and epigastralgia, was investigated and all preoperative findings were suggestive of a tumour of the duodenum. During the scheduled pancreaticoduodenectomy a mass, resultant to a polyp, was palpatory felt inside the duodenum and then successfully and completely resected through a duodenotomy avoiding surgical overtreatment and connected postoperative morbidities. Histological analysis showed hyperplasia of Brunner's glands correspondent to a Brunner's gland hamartoma. BGH was undiagnosed before surgery, due to its particular sub-mucosal growth simulating an expanding process starting from the duodenum, and secondly due to unsuccessful biopsies performed during endoscopic procedure.

CONCLUSION

BGH is a rare lesion featuring, when symptomatic, obstructive or bleeding symptoms. Surgical treatment represents the gold standard approach in case of lesions that are technically impossible to remove endoscopically or in case of an undiagnosed lesion. Herein, we report a case of a patient presenting with a duodenal lesion mimicking, in all preoperative findings, a tumour of the duodenum. Duodenotomy and resection of the BGH provided a definitive cure avoiding surgical overtreatment. An intraoperative deep analysis of all surgical cases still remain crucial for a right therapeutic choice even in a new era for surgical technology. For similar intraoperative findings we recommend this technique.

Autoimmune metaplastic atrophic gastritis in chinese: a study of 320 patients at a large tertiary medical center

OBJECTIVES

Autoimmune metaplastic atrophic gastritis (AMAG) is an uncommon disease worldwide and may predispose to gastric carcinoid tumors or adenocarcinomas. The aims of this study were to outline the clinical characteristics of Chinese AMAG patients, including demographic pattern, hematologic features, and gastroscopic and histopathologic findings.

PATIENTS AND METHODS

A total of 320 Chinese patients with AMAG, from January 2007 to December 2014, were reviewed in a regional hospital of China.

RESULTS

Of the 320 AMAG patients, the mean age was 60.6 ± 12.3 years [range 26-86; 206 (64.4%) women]. The coarse annual detection rate was 0.9%. Anemia was present in only 19.3% patients (53/275) and 3.5% (11/315) AMAG patients also had primary biliary cirrhosis. One hundred and thirty-six had endoscopically identifiable lesions. These lesions consisted of 130 polypoid lesions (63 hyperplastic polyps, 2 oxyntic mucosa pseudopolyps, 2 intestinal-type gastric adenomas, 2 fundic gland polyps, 5 concurrent polyps, 14 well-differentiated neuroendocrine neoplasms, 7 submucosal tumors and 35 chronic gastritis), 6 adenocarcinomas. The detection rate of atrophy and intestinal metaplasia in antral mucosa were 47.2 and 37.5%, respectively.

CONCLUSIONS

AMAG is more frequent than expected in China and display a female predominance, accompanied with other autoimmune disorders. AMAG should be paid more attention by clinicians through a multidisciplinary team approach.

Endoscopic ultrasonographic characteristics of gastric schwannoma distinguished from gastrointestinal stromal tumor

BACKGROUND/AIMS

Gastric schwannoma (GS), a rare neurogenic mesenchymal tumor, is usually benign, slow-growing, and asymptomatic. However, GS is often misdiagnosed as gastrointestinal stromal tumors (GIST) on endoscopic and radiological examinations. The purpose of this study was to evaluate EUS characteristics of GS distinguished from GIST.

METHODS

A total of 119 gastric subepithelial lesions, including 31 GSs and 88 GISTs, who were histologically identified and underwent EUS, were enrolled in this study. We evaluated the EUS characteristics, including location, size, gross morphology, mucosal lesion, layer of origin, border, echogenic pattern, marginal halo, and presence of an internal echoic lesion by retrospective review of the medical records.

RESULTS

GS patients comprised nine males and 22 females, indicating female predominance. In the gross morphology according to Yamada's classification, type I was predominant in GS and type III was predominant in GIST. In location, GSs were predominantly located in the gastric body and GISTs were predominantly located in the cardia or fundus. The frequency of 4th layer origin and isoechogenicity as compared to the echogenicity of proper muscle layer was significantly more common in GS than GIST. Although not statistically significant, marginal halo was more frequent in GS than GIST. The presence of an internal echoic lesion was significantly more common in GIST than GS.

CONCLUSIONS

The EUS characteristics, including tumor location, gross morphology, layer of origin, echogenicity in comparison with the normal muscle layer, and presence of an internal echoic lesion may be useful in distinguishing between GS and GIST.

Endosonographic Features of Gastric Schwannoma: A Single Center Experience

BACKGROUND/AIMS

Gastric schwannomas are rare benign mesenchymal tumors that are difficult to differentiate from other mesenchymal tumors with malignant potential, such as gastrointestinal stromal tumors. This study aimed to evaluate the characteristic findings of gastric schwannomas via endoscopic ultrasonography (EUS).

METHODS

We retrospectively reviewed the EUS findings of 27 gastric schwannoma cases that underwent surgical excision at Pusan National University Hospital during 2007 to 2014.

RESULTS

Gastric schwannomas were mainly located in the middle third of the stomach with a mean tumor size of 32 mm. All lesions exhibited hypoechoic echogenicity, and 24 lesions (88.9%) exhibited heterogeneous echogenicity. Seventeen lesions (63.0%) exhibited decreased echogenicity compared to the normal proper muscle layer. Distinct borders were observed in 24 lesions (88.9%), lobulated margins were observed in six lesions (22.2%), and marginal haloes were observed in 24 lesions (88.9%). Hyperechogenic spots were observed in 21 lesions (77.8%), calcifications were observed in one lesion (3.7%), and cystic changes were observed in two lesions (7.4%).

CONCLUSIONS

During EUS, gastric schwannomas appear as heterogeneously hypoechoic lesions with decreased echogenicity compared to the normal proper muscle layer. These features may be helpful for differentiating gastric schwannomas from other mesenchymal tumors.

Pathophysiological and clinical aspects of gastric hyperplastic polyps

Gastric polyps become a major clinical problem because of high prevalence and tendency to malignant transformation of some of them. The development of gastric hyperplastic polyps results from excessive proliferation of foveolar cells accompanied by their increased exfoliation, and they are macroscopically indistinguishable from other polyps with lower or higher malignant potential. Panendoscopy allows detection and differentiation of gastric polyps, usually after obtaining histopathological biopsy specimens. Unremoved gastric hyperplastic polyps may enlarge and sometimes spontaneously undergo a sequential progression to cancer. For this reason, gastric hyperplastic polyps larger than 5 mm in size should be removed in one piece. After excision of polyps with atypical focal lesion, endoscopic surveillance is suggested depending on histopathological diagnosis and possibility of confirming the completeness of endoscopic resection. Because of the risk of cancer development also in gastric mucosa outside the polyp, neighboring fragments of gastric mucosa should undergo microscopic investigations. This procedure allows for identification of patients who can benefit most from oncological endoscopic surveillance. If Helicobacter pylori (H. pylori) infection of the gastric mucosa is confirmed, treatment strategies should include eradication of bacteria, which may prevent progression of intestinal metaplasia. The efficacy of H. pylori eradication should be checked 3-6 mo later.

Endoscopic resection for duodenal subepithelial tumors: a single-center experience

BACKGROUND

Subepithelial tumors (SETs) in the gastrointestinal tract are often incidentally found during endoscopic examinations. Although the utility and safety of endoscopic resection (ER) of SETs in the esophagus and stomach have been described, data about the ER of duodenal SETs remain scant. Therefore, we aimed to investigate the clinical outcomes associated with the ER of duodenal SETs and to assess possible predictive factors for incomplete resection.

METHODS

We conducted a retrospective observational study of 62 patients (64 lesions) that underwent ER of duodenal SETs between June 2005 and December 2015 at the Pusan National University Hospital. The therapeutic outcomes from ER and procedure-related complications were analyzed.

RESULTS

Endoscopic mucosal resection (EMR) was performed in 38 tumors, EMR with a ligation device (EMR-L) in 18 and endoscopic submucosal dissection (ESD) in 8. The overall en bloc resection and complete ER rates were 96.9 % (62/64) and 100 % (64/64), respectively. The complete pathologic resection rate was 76.6 % (49/64). Multivariate logistic regression analyses determined that the macroscopic type (Yamada type I or II; odds ratio [OR] 6.460, 95 % confidence interval [CI] 1.569-37.458, p = 0.027) and the treatment method (ESD; OR 7.178, 95 % CI 1.291-39.323, p = 0.024) were independently associated with incomplete pathologic resection. The procedure-related bleeding and perforation rates were 6.3 % and 4.7 %, respectively. No recurrences were observed in patients who had undergone complete ER at a median follow-up period of 20 months (range 6-112 months).

CONCLUSION

ER is an effective, safe, and feasible treatment for duodenal SETs, especially when the SET is located in the deep mucosal layer and/or the submucosal layer.

Endosonographic features of histologically proven gastric ectopic pancreas

Gastric ectopic pancreas is an uncommon developmental anomaly and its histological diagnosis is usually difficult by using a conventional biopsy forceps. In the literature, most cases of gastric ectopic pancreas were usually diagnosed by gross pattern during endoscopic examination or features of endoscopic ultrasound. In contrast, this disease was seldom diagnosed by histology in clinical practice. Although the typical endoscopic ultrasonographic features of ectopic pancreas include heterogeneous echogenicity, indistinct borders, and a location within 2 or more layers, it can also exhibit hypoechoic homogeneous echogenicity and a distinct border within the fourth sonographic layer (muscularis propria) similar to the endoscopic ultrasonographic features of gastrointestinal stromal tumors. In our study, we found that 53% of gastric ectopic pancreas originated within the fourth sonographic layer, demonstrating hypoechoic, homogeneous echogenicity, and distinct borders. Therefore, recognizing endoscopic ultrasonographic features, combining with deep biopsy, endoscopic ultrasound-guided fine needle aspiration/core needle biopsy can prevent conducting unnecessary resection. Surgical resection is the mainstay treatment for symptomatic gastric ectopic pancreas, but endoscopic resection using endoscopic mucosal resection or endoscopic submucosal dissection technique provides an alternative method of removing superficial-type and deep-type gastric ectopic pancreas.

Endoscopic resection of gastrointestinal lipomas: a single-center experience

BACKGROUND

Gastrointestinal (GI) lipomas are benign, slow-growing subepithelial tumors. Most lipomas are detected incidentally at endoscopy, but they can cause GI bleeding, abdominal pain, intestinal obstruction, and intussusception, particularly if they are larger than 2 cm in diameter. The aim of this study was to investigate the efficacy, safety, and long-term prognosis of endoscopic treatment of GI lipomas.

METHODS

A total of 28 GI lipomas treated endoscopically from January 2005 to June 2012 were retrospectively reviewed. Endoscopic treatment was performed by four methods: the unroofing technique, endoscopic mucosal resection (EMR), EMR after precutting (EMR-P), and endoscopic submucosal dissection (ESD).

RESULTS

Of 28 GI lipomas, 5 were located in the stomach, 2 in the duodenum, and 21 in the colon. Thirteen lipomas were <2 cm in diameter (small lipoma), and the other 15 were ≥2 cm (large lipoma). The unroofing technique was performed in 2 cases, EMR in 17 cases, EMR-P in 4 cases, and ESD in 5 cases. En bloc resection was performed with 21 lesions (75 %), and endoscopic complete resection was achieved with 26 lesions (93 %). Incomplete resection occurred in the 2 cases treated by the unroofing technique. On pathologic examination, complete resection was achieved with 21 lesions (75 %). Delayed bleeding was observed in one patient. There were no serious complications such as perforation or post-procedural stricture. During the mean follow-up period of 19 months (range 2-91 months), no recurrence was observed.

CONCLUSIONS

Endoscopic treatment appears to be a safe and effective treatment for GI lipomas, including large lipomas (≥2 cm in diameter).

Endoscopic resection of granular cell tumors in the gastrointestinal tract: a single center experience

BACKGROUND

The frequency of granular cell tumors (GCTs) identified in the gastrointestinal tract has recently increased with the increased use of routine endoscopy. Endoscopic treatment is increasingly used as an alternative to traditional surgical resection, but there are few reports on the efficacy, safety, and long-term prognosis of endoscopic treatment for GCTs. The aim of this study was to assess the efficacy, safety, and long-term prognosis of endoscopic resection for the gastrointestinal GCTs.

METHODS

We examined a total of 27 GCTs in 25 patients who were treated by endoscopic resection from January 2007 to February 2011. For endoscopic resection, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) was used.

RESULTS

Twenty GCTs were located in the esophagus, 5 in the stomach, and 2 in the colon. The median size of the GCTs was 10 mm; the largest size, located in the ascending colon, measured 18 mm. EMR with a ligation device was performed in 20 cases, conventional EMR in 5 cases, and ESD in 2 cases. En bloc resection was performed in 25 cases (92.6%), and endoscopic complete resection piecemeal resection was achieved in 25 cases (92.6%). Pathologic complete resection was achieved in 22 lesions (81.5%). Intraprocedural bleeding was noted in three patients, with no occurrence of perforation or postprocedure stricture. No recurrence was observed during the mean follow-up period of 15 months (range 9-31 months).

CONCLUSIONS

Endoscopic resection appears to be a safe and effective treatment for GCTs in the gastrointestinal tract.

Correlation between magnifying narrow band imaging and histopathology in gastric protruding/or polypoid lesions: a pilot feasibility trial

Background

Several study showed usefulness of microscopic capillaries, seen by magnifying narrow band imaging (NBI) endoscopy for predicting histopathology among superficial depressed or flat elevated gastric neoplasia (GN). Here we assessed the diagnostic efficacy of magnifying NBI for predicting histopathology among gastric protruding/or polypoid lesions.

Methods

Using endoscopic pictures of magnifying NBI from 95 protruding/or polypoid lesions (19 fundic gland polyps: FGP, 47 hyperplastic polyps: HP, and 29 GN), fine mucosal patterns were classified into four categories: small round, prolonged, villous or ridge, and unclear patterns, and micro vascular patterns were classified into five categories: honey comb, dense vascular, fine net work, core vascular, and unclear patterns.

Results

Most suggestive micro vascular patterns for predicting FGP, and HP were honeycomb (sensitivity 94.7%, specificity 97.4%), and dense vascular patterns (sensitivity 93.6%, specificity 91.6%), respectively. Fine net work, core vascular, and unclear patterns presented higher specificity (97%, 100%, and 100%) for predicting GN, and diagnostic efficacy of combined of those patterns was favorable (sensitivity 86.2%, specificity 97.0%).

Conclusion

Micro vascular patterns by using magnifying NBI provides meaningful information for predicting the histopathology of gastric protruding/or polypoid lesions.

Endosonographic features of esophageal granular cell tumors using a high-frequency catheter probe

OBJECTIVE

Submucosal tumors (SMTs) are occasionally found in the esophagus during upper endoscopy. Granular cell tumors (GCTs) are reported to be the second most common esophageal mesenchymal tumors, after leiomyomas. Endoscopic ultrasonography (EUS) is an effective tool for predicting the histologic characteristics of SMTs by providing an accurate image of the layering structure of the esophagus, but it is hard to differentiate GCTs from submucosal leiomyomas accurately with conventional EUS. The aim of the present study was to characterize the EUS features of GCTs compared with those of submucosal leiomyomas using a high-frequency catheter probe EUS.

MATERIAL AND METHODS

A total of 41 patients with GCTs or submucosal leiomyomas were included. All of the patients underwent EUS before histologic confirmation by endoscopic resection or biopsy.

RESULTS

There were 14 GCTs in 12 patients and 30 leiomyomas in 29 patients. GCTs had a white-to-yellow surface color more frequently than leiomyomas. In comparison with the surrounding normal proper muscle layer, the echogenicity of the leiomyomas was similar to that of the surrounding muscle layer, but more than half of the GCTs were hyperechoic compared to the surrounding muscle layer. Unclear borders were observed more frequently in GCTs than in leiomyomas. The presence of at least two of these three features in a given tumor had a sensitivity of 85.7%, a specificity of 96.7%, and an accuracy of 93.2% for predicting GCTs.

CONCLUSIONS

High-frequency probe EUS is helpful for differentiating esophageal GCTs from submucosal leiomyomas.

Gastric polyps: a retrospective analysis of 26,000 digestive endoscopies

BACKGROUND

Gastric polyps are small gastric lesions, asymptomatic in most cases and are generally discovered inadvertently during upper digestive endoscopy.

AIM

To retrospectively review the characteristics and frequency of gastric polyps, derived from the gastric mucosal epithelium in a large series of endoscopies.

METHODS

One hundred and fifty three patients in a series of 26,000 consecutive upper digestive endoscopies done over a 5-year period, being that each patient had only one examination were analyzed and their histological and Yamada classification, as well as their location, size, histopathological findings and treatment studied. All patients had at least one gastric polyp, as confirmed by histological examination.

RESULTS

The polyps were classified as hyperplastic, adenomatous and fundic gland polyps. The most of them measure less than 1 cm (hyperplastic polyps - 60,5%; adenomatous polyps - 73,6%; fundic gland polyps - 72%). Hyperplastic polyps were the most frequent and accounted for 71.3% of the cases, whereas fundic gland polyps accounted for 16.3% and adenomatous polyps for 12.4%. Hyperplastic and adenomatous polyps were primarily single, whereas fundic gland polyps tended to be multiple. A carcinoma was detected in one hyperplastic polyp (0.9%) and in two adenomatous polyps (10.5%). High grade dysplastic foci were found in four adenomatous polyps (21%).

CONCLUSIONS

The digestive endoscopy is the safest and efficient method for the diagnosis of the gastric polyps, that in most of the patients does not show characteristic symptoms. The histopathological definition is not possible to the endoscopic glance being needed the pathologist's aid, once the conduct to be adopted will depend on the result of the biopsy.

Evaluation of tumor growth rate in patients with early gastric carcinoma of the elevated type

The growth rates of elevated-type early gastric carcinoma in 12 patients were determined chronologically using serial radiographs. Eight progressed from an early to an advanced stage during periods of observation ranging from 4-82 months (mean 31.7 months), while four patients were still in an early stage at final examination, despite an increase in tumor size. The tumor volume doubling months) but varied considerably among patients. Aggressive endoscopy should be performed for all elevated lesions of the stomach because they can harbor malignancy; some can grow rapidly as reported here.

Gastric hamartomatous polyp without polyposis coli: radiologic diagnosis

Gastric hamartomatous polyps were found in 25 patients over a period of 4 1/2 years, for an incidence of 11% in all endoscopically biopsied polyps. The number of polyps was fewer than 5 in most patients. All polyps were sessile, sharply demarcated, hemispheric protrusions, measuring up to 10 mm in diameter but most were less than 5 mm. The most characteristic finding differing from hyperplastic polyps, adenoma, and polypoid carcinoma was that hamartomatous polyps were located in the fundic gland mucosa, which was demonstrated as a rugal area on moderately distended double-contrast radiographs.

Radiologic examination in gastric cancer. A retrospective study of 188 patients

The accuracy in the diagnosis of gastric cancer was investigated in 188 histologically proven cases, including 12 cases of early gastric cancer. One hundred and sixty-five of 167 patients (99%) were recorded radiologically as having a gastric lesion. The initial diagnosis was carcinoma in 144 patients (86%), and benign lesion in 21 cases (13%). In 2 cases (1%) no abnormalities were seen. In 3 out of 9 patients with a partial gastrectomy (33%) an incorrect diagnosis was made. In 11 of 12 patients with early gastric cancer the radiologic examination revealed abnormal findings, but 7 of these were incorrectly interpreted as benign. A retrospective analysis of the radiologic examination in which no malignancies were reported showed that inadequacy of the examination technique and misinterpretation of radiologic signs of malignancy were the main causes of failure in diagnosing of malignancy. The rate of misinterpretation of malignancy as a benign lesion (13%) justifies the endoscopic control of every radiologically detected abnormality. The high sensitivity in detecting a lesion indicates, however, that a biphasic radiologic examination is a safe screening method in gastric cancer. Endoscopy with biopsy showed a lesion in 156 out of 160 patients (98%), but in 11 of these (7%) the initial examination did not yield histologic proof of malignancy. In 4 patients (2%) no abnormalities were observed by endoscopists. One hundred and forty-nine patients were examined with both radiology and endoscopy with biopsy. A malignant lesion with recognition of its malignant character was defined in 144 cases (97%).

Double versus single contrast gastrointestinal radiology

With experience, air contrast examination of the esophagus, stomach, and duodenum can be performed routinely as quickly and easily as the standard UGI. The air contrast examination is superior for detection of small gastric polyps and the Japanese have found it superior for detection of early carcinoma. The postoperative stomach and the fundus and cardia are most easily examined by air contrast. Clear superiority in the diagnosis of peptic ulcers and peptic esophagitis has not been proved. The most accurate routine examination may be a multiphasic or combined approach utilizing air contrast views as well as filled compression views and careful fluoroscopy. With respect to the colon, we do not suggest that air contrast BE must be done exclusively. However, it is superior for the detection of polyps and small carcinomas. The technique should be available in all radiology departments and should be an integral part of the evaluation of patients at increased risk of developing carcinoma. This includes patients over 40 years of age, with chronic ulcerative colitis, familial multiple polyposis or Gardner's syndrome, family history of inherited cancer, and medical history of adenomatous polyps, colorectal cancer, or female genital cancer. In addition, air contrast enema should be utilized for the sensitive and accurate evaluation of early inflammatory bowel disease. Finally, with respect to the colon examination one fact must be stressed. Irregardless of full column or air contrast method, most missed lesions are due to poor bowel preparation, poor technique, or perceptive error by the radiologist. There can be no substitute for a clean colon, meticulous attention to technical details, and careful review of the radiographs.

Double contrast examination of the stomach compared with endoscopy

The results of the double examination of the stomach in a series of 102 patients were compared with the findings at endoscopy. Nasogastric intubation was used to introduce the air into the stomach. Hypotonia was achieved mainly with glucagon. The radiologic error rate was 10 per cent, consisting of 7 per cent false negative and 3 per cent false positive findings. The diagnostic advantages of the double contrast technique over those of the conventional barium examination are discussed.