Gastric adenocarcinoma of the fundic gland type: A case report

INTRODUCTION

Gastric adenocarcinoma of the fundic gland type (GA-FG) is a newly described entity that is characterized by well-differentiated neoplasm with unclear etiopathogenesis.

PATIENT CONCERNS

A 60-year-old Chinese man was referred to our hospital for abdominal distension.

DIAGNOSIS

Esophagogastroduodenoscopy (EGD) showed a depressed lesion found using in the greater curvature of the stomach. The pathological diagnosis of the biopsy specimens indicated that the tumor was GA-FG (chief cell predominant type, GA-FG-CCP).

INTERVENTIONS

Endoscopic submucosal dissection (ESD) was performed. The histopathological examination of the ESD specimen revealed gastric hyperplasia of the fundic gland type around the adenocarcinoma cells.

OUTCOMES

The surgical outcomes were good. The EGD showed a scar with no recurrence, and no symptoms were observed 1 year postoperatively during the follow-up.

CONCLUSION

We present a rare case of a depressed lesion with a pathogenic expression suggesting gastric hyperplasia of the fundic gland type around the adenocarcinoma cells. Considering the origin of oxyntic mucosa, we consider that it may develop into GA-FG. To understand this issue better, similar cases should be monitored in the future.

A Case of Adenocarcinoma of the Upper Third of the Esophagus Arising on Ectopic Gastric Tissue

A case of adenocarcinoma of the upper third of the esophagus, arising from ectopic mucosa of gastric type, is described. The possible origins, from ectopic islets of gastric mucosa, tracheobronchial rests or esophageal glands, are discussed. The precence of ectopic gastric mucosa on the surface of the esophagus adjacent to the tumor suggests that this esophageal adenocarcinoma arose from ectopic gastric mucosa.

Gastric foregut cystic developmental malformation: Case series and literature review

Foregut cystic developmental malformation (FCDM) is a very rare lesion of the alimentary tract, especially in the stomach. We discuss the concepts of gastric duplication cyst, bronchogenic cysts, and FCDM. Nomenclature has been inconsistent and confusing, but, by some definitions, gastric duplication cysts involve gastric mucosa and submucosal glands, bronchogenic cysts involve respiratory mucosa with underlying cartilage and glands, and FCDM lacks gastric mucosa or underlying glands or cartilage but has pseudostratified ciliated columnar epithelium (PCCE). We searched our departmental case files from the past 15 years and identified 12 cases of FCDM in the alimentary tract. We summarize the features of these 12 cases including a report in detail on a 52-year-old man with a submucosal cyst lined with simple PCCE and irregular and stratified circular muscle layers that merged with gastric smooth muscle bundles near the lesser curvature of the gastric cardia. A literature review of cases with this histology yielded 25 cases. We propose the term gastric-FCDM for such cases. Our own series of 12 cases confirms that preoperative recognition of the entity is infrequent and problematic. The rarity of this developmental disorder, as well as a lack of understanding of its embryologic origins, may contribute to missing the diagnosis. Not appreciating the diagnosis preoperatively can lead to an inappropriate surgical approach. In contrast, presurgical recognition of the entity will contribute to a good outcome and reduced risk of complications.

Rare adult gastric duplication cyst mimicking a gastrointestinal stromal tumor

Gastric duplication cyst is a very rare gastrointestinal tract malformation that accounts for 2%-4% of alimentary tract duplications. Most cases are diagnosed within the first year of life, following presentation of abdominal pain, vomiting, and weight loss and clinical discovery of an abdominal palpable mass. This case report describes a very uncommon symptomatic gastric duplication cyst diagnosed for the first time in adulthood. Only a few other case reports of similar condition exist, and all were identified by endosonography. The current case involves a 52-year-old male who presented with a one-month history of progressive iron deficiency anemia without overt gastrointestinal bleeding. The patient underwent esophagogastroduodenoscopy, which revealed a 2.0 cm pinkish subepithelial lesion, suspected to be a gastrointestinal stromal tumor (GIST) and source of gastrointestinal bleeding. The endosonography showed inhomogeneous hypoechoic lesions with focal anechoic areas arising from a second and third layer of the gastric wall. Differential diagnoses of GIST, neuroendocrine tumor, or pancreatic heterotopia were made. The lesion was removed using an endoscopic submucosal resection technique. Histopathology revealed an erosive gastric mass composed of a complex structure of dilated gastric glands surrounded by fibro-muscular tissue, fibroblasts, and smooth muscle bundles, which led to the diagnosis of gastric duplication.

[A case of diffuse cystic malformation in which submucosal tumor-like advanced gastric cancer was identified during 10-year follow-up]

A 66-year-old man with giant gastric folds had been followed up since February 2000. In March 2010, a submucosal tumor of 35mm was identified with endoscopy and a low echoic mass was identified with endoscopic ultrasonography. After histologic diagnosis by endosonography-guided fine needle aspiration biopsy, he underwent a total gastrectomy. Histologic examination of the resected specimen revealed a tumor 20mm in diameter consisting of well-to-moderately differentiated tubular adenocarcinoma in the thickened wall of the gastric greater curvature, which contained small cystic lesions in the lamina propria. Immunohistochemical staining showed thick gastric wall consisting of not only multiple cysts but also smooth muscle, elastic and collagen fibers. The histologic diagnosis was advanced gastric cancer accompanied by diffuse cystic malformation (DCM). Although it is a rare condition, DCM should be considered in the differential diagnosis of giant gastric folds and as a pre-cancerous lesion.

The Floating Meckel

A 10-year-old girl was hospitalized because of abdominal pain and significant gastrointestinal bleeding for 3 days with hematocrit of 28% and hemoglobin of 6.1 mmol/L. Gastroscopy and abdominal ultrasound did not reveal any gastrointestinal abnormalities and parameters of coagulation were normal. Because a Meckel diverticulum is one of the most common causes of lower gastrointestinal bleeding in children, a Tc-99m pertechnetate scan (Meckel's scan) was performed to identify ectopic gastric mucosa. Normally, a Meckel diverticulum is found in the right lower quadrant.

Molecular forms of trefoil factor 1 in normal gastric mucosa and its expression in normal and abnormal gastric tissues

AIM: To study the molecular forms of trefoil factor 1 (TFF1) in normal gastric mucosa and its expression in normal and abnormal gastric tissues (gastric carcinoma, atypical hyperplasia and intestinalized gastric mucosa) and the role of TFF1 in the carcinogenesis and progression of gastric carcinoma and its molecular biological mechanism underlying gastric mucosa protection.

METHODS: The molecular forms of TFF1 in normal gastric mucosa were observed by Western blot. The expression of TFF1 in normal and abnormal gastric tissues (gastric carcinoma, atypical hyperplasia and intestinalized gastric mucosa) was also assayed by immunohistochemical method. The average positive AO was estimated by Motic Images Advanced 3.0 software.

RESULTS: Three patterns of TFF1 were found in normal gastric mucosa: monomer, dimmer, and TFF1 compound whose molecular weight is about 21 kDa. The concentration of TFF1 compound was the highest among these three patterns. TFF1 was expressed mainly in epithelial cytoplasm of the mucosa in gastric body and antrum, especially around the nuclei. The closer the TFF1 to the lumen, the higher the expression of TFF1. The expression of TFF1 in peripheral tissue of gastric carcinoma (0.51 ± 0.07) was higher than that in normal gastric mucosa (0.44 ± 0.06, P < 0.001). The expression of TFF1 in gastric adenocarcinoma was positively related to the differentiation of adenocarcinoma. The lower the differentiation of adenocarcinoma was, the weaker the expression of TFF1. No TFF1 was expressed in poorly-differentiated adenocarcinoma. The expression of TFF1 in moderately-well differentiated adenocarcinoma (0.45 ± 0.07) was a little lower than that in normal mucosa (P > 0.05). The expression of TFF1 in gastric mucosa with atypical hyperplasia (0.57 ± 0.03) was significantly higher than that in normal gastric mucosa (P < 0.001). No TFF1 was expressed in intestinalized gastric mucosa. There was no statistically significant difference between the expressions of TFF1 in gastric mucosa around the intestinalized tissue (0.45 ± 0.07) and normal gastric mucosa (P > 0.05).

CONCLUSION: TFF1 is expressed mainly in epithelial cytoplasm of the mucosa in gastric body and antrum. Its main pattern is TFF1 compound, which may have a greater biological activity than monomer and dimer. The expression of TFF1 in peripheral mucosa of gastric ulcer is higher than that in mucosa 5 cm beyond the ulcer, indicating that TFF1 plays an important part in protection and restitution of gastric mucosa. The expression of TFF1 is increased in peripheral tissues of gastric carcinoma and gastric mucosa with atypical hyperplasia, but is decreased in cancer tissues, implying that TFF1 may be related to suppression and differentiation of carcinoma. The weaker expression of TFF1 in poorly-differentiated carcinoma may be related to the destruction of glands and cells in cancer tissues and the decrease in secretion of TFF1.

Antral mucosal valve: a rare cause of gastric outlet obstruction in newborn

A 15-day male neonate presented with postprandial nonbilious vomiting. Barium meal suggested pyloric obstruction. Ultrasound of the stomach after saline loading revealed an echogenic antral valve. Subsequent laparotomy confirmed the ultrasound findings. Excision of the valve resulted in excellent recovery. To our knowledge, gastric outlet obstruction because of an antral mucosal valve in a neonate has not previously been described.

Sonographic demonstration of cervical esophageal web

We report a case of esophageal web demonstrated with sonography in a 45-year-old woman with dysphagia. The esophageal web was incidentally detected as a circumferential hypoechoic membrane on sonograms of the cervical esophagus.

Split Notochord Syndrome: Ileal Duplication Causing Intermittent Episodes of Vomiting

Split notochord syndrome is a group of developmental abnormalities caused by abnormal splitting or deviation of the notochord, clinically resulting in the duplicated bowel associated with vertebral anomalies. In this syndrome, initial presentations due to duplicated bowel, vomiting, abdominal pain, and failure to thrive, usually occur before 1 year of age. We here report a 12-year-old boy with intermittent vomiting, previously diagnosed with cyclic vomiting syndrome. On abdominal x-ray examination, a defect in the closure of posterior vertebral arches was observed in the 5th lumbar vertebral body, indicating the complication of spina bifida occulta. This finding suggested the diagnosis of split notochord syndrome. A magnetic resonance imaging study revealed a cystic mass lesion in the pelvic cavity. (99m)Tc-pertechnetate scintigraphy, which is frequently used to detect ectopic gastric mucosa for the diagnosis of Meckel's diverticulum, showed a positive spot corresponding to the cystic mass lesion. Surgical resection of the cystic mass lesion demonstrated ileal duplication with ectopic gastric mucosa. Surgical findings suggest that symptoms of the patient were due to ulceration, inflammation, or bleeding caused by acid-peptic juice secreted from ectopic gastric mucosa. Duplication of the alimentary tract should be considered as a possible cause in patients with symptoms suggesting cyclic vomiting syndrome.

[Endoscopic sclerosis of bleeding caused by Dieulafoy's lesion]

The upper gastrointestinal bleeding by Dieulafoy's lesion is a rare cause of bleeding, it is a massive haemorrhage and it is difficult to diagnose. Endoscopy is the diagnostic method of choice, in many cases are necessary repeated examinations. Endoscopic therapy is the therapeutic approach of choice, it can achieve the hemostasis in more than 90% of cases; combined therapy methods being more effective than single monotherapy. Surgical treatment remains for cases of uncontrolled hemorrhaging. Dieulafoy's lesion is a rare condition. We have only two nation wide reports. We present two cases of patients with gastric Dieulafoy's lesion with active bleeding which were successfully treated with injection endoscopic of epinephrine and absolute alcohol therapy, showing no relapse of bleeding after 12 months. They did not present other episode of haemorrhage during the twelve months after initial bleeding.

Laparoscopic resection of gastric duplication: successful treatment of a rare entity

Alimentary tract duplications are rare congenital malformations that may be found anywhere from mouth to anus. They usually share a common smooth muscle wall and blood supply with the adjacent bowel. Some duplications are asymptomatic but most cause problems in early childhood. Gastric duplications account for 2% to 7% of all gastrointestinal duplications. The management of gastric duplication is essentially surgical. The treatment of choice is the complete excision of the gastric duplication without violation of the gastric lumen whenever possible. The authors report an unusual case of gastroesophageal junction duplication completely removed by laparoscopy. To our knowledge, this is the first case of gastric duplication successfully treated by laparoscopy in English literature. Laparoscopic resection may be added to the surgical armamentarium in the treatment of alimentary tract duplications.

Double Dieulafoy-like lesion in the stomach

Dieulafoy's lesion is an uncommon cause of major gastrointestinal bleeding and may be difficult to recognize. It consists of an arteriole that protrudes through a tiny mucosal defect usually within 6 cm of the gastroesophageal junction on the lesser curve of the stomach. Despite widespread awareness of this entity, it remains a diagnostic challenge for gastroenterologists because of its small size and hidden location. Emergency endoscopy is the most effective method of diagnosing the disease. We report a patient, with double Dieulafoy-like lesion, who was successfully treated endoscopically using hemostatic clip application. The characteristics of the Dieulafoy's lesion, its current diagnosis, and its treatment are discussed.

Fine needle aspiration biopsy of gastric duplication cysts with endoscopic ultrasound guidance

OBJECTIVE

To evaluate the ability of endoscopic ultrasound (EUS)-guided fine needle aspiration biopsy (FNAB) to diagnose gastric duplication cysts.

STUDY DESIGN

FNAB reports from the Department of Pathology, Saint Louis University Hospital, were retrospectively searched for reports of EUS-guided FNABs of the stomach. These reports were then reviewed to find instances in which gastric duplication cysts were diagnosed. The charts of patients diagnosed with gastric duplication cysts were reviewed.

RESULTS

Two patients were identified. The first was a 35-year-old, Caucasian male with an asymptomatic submucosal (versus extrinsic) gastric mass discovered during computed tomography of the abdomen. The second was a 44-year-old, Caucasian male with a history of treated low grade B cell lymphoma of mucosa-associated lymphoid tissue (MALToma) who was found to have an asymptomatic gastric wall abnormality by EUS when undergoing follow-up for the MALToma. Respiratory-type epithelial cells were present in each of these gastric duplication cysts. At this writing, both patients were being followed clinically and with imaging.

CONCLUSION

Gastric duplication cysts, particularly those that have respiratory-type epithelium, can be diagnosed by EUS-guided FNAB. The diagnosis of gastric duplication cysts by EUS-guided FNAB can preclude surgery, with its associated morbidity.

[The place of endoscopic treatment in other causes of upper gastrointestinal haemorrhage]

IN MALLORY-WEISS SYNDROME: With fissuring of the cardial area, probably subsequent to a rapid increase in intra-gastric pressure, hemorrhagic Mallory-Weiss syndrome may justify haemostatic endoscopic treatment. However, one should not forget that the majority of these syndromes usually regress spontaneously. IN DIEULAFOY'S ULCERS: Loss of substance destroying the muscle mucosa, Dieulafoy's ulcer would be at the origin of around 2% of upper gastrointestinal haemorrhages. Initial haemostasis can be obtained using endoscopic treatment in 85% of cases. The mechanical methods (clips, elastic ligature) are probably more effective than injections, but they are still under assessment.

[The endoscopic diagnosis and therapy as well as the long-term course of Dieulafoy ulcer hemorrhage]

OBJECTIVE

To assess the effectiveness of endoscopic diagnosis and treatment as well as the long-term course in patients with bleeding from Dieulafoy's ulcer (DU).

PATIENTS AND METHODS

Data were gathered on all cases coded "bleeding from Dieulafoy's ulcer" in an endoscopic data-bank. The following items were obtained from the case-notes: clinical symptoms, mean haemoglobin concentration, demand for infusion of erythrocyte concentrates and endoscopic procedures undertaken for diagnosis and treatment. There were 15 patients (mean age 64.8 years; 9 men and 6 women), seen between 1985 and 1998 with the diagnosis of DU. All lesions were located in the proximal stomach. The effectiveness of the various parameters was analysed. The long-term course was ascertained by telephone interviews with the patients and (or) their general practitioner.

RESULTS

The suspected diagnosis of DU was confirmed by additional endoscopic means such as endoscopic Doppler sonography or endosonography. A combination of endoscopic techniques of stopping the bleeding (epinephrine injection and, if necessary, haemoclip application) was effective in 14 of the 15 patients, operative intervention being required in one. Three patients died during follow-up, none of bleeding. No recurrence of bleeding had occurred in the 10 patients followed for a mean of 20 (6-31) months.

CONCLUSIONS

The endoscopic diagnosis of DU bleeding can be confirmed by endoscopic Doppler sonography or endosonography. It remains to be proven whether miniscope endosonography is of additional value. The combined method of stopping the bleeding has been effective in this patient collective, both during hospitalization and on long-term follow-up.

Familial occurrence of congenital incomplete prepyloric mucosal diaphragm

Incomplete prepyloric mucosal diaphragm (IPMD) is an uncommon congenital anomaly that leads to gastric outlet obstruction in infancy and childhood. This report describes the occurrence of IPMD in six children in a closely knit tribal family from a geographically isolated desert town with a small population in the Sahara. Their records showed similarities of clinical, radiological, operative, and histopathological features. These features, as well as its occurrence in brothers, sisters, and cousins, suggest that this unusual anomaly is transmitted as an autosomal recessive trait.

Congenital alimentary tract abnormalities presenting in adolescence and young adulthood

Intestinal atresias and duplications of the alimentary tract commonly present in the neonatal period or early infancy, but in rare cases they can persist and present de novo during adolescence. We report on these two abdominal congenital anomalies, the clinical presentations of which in adolescence and young adulthood are unique.

The mesenchymal winged helix transcription factor Fkh6 is required for the control of gastrointestinal proliferation and differentiation

The winged helix transcription factor Fkh6 is expressed in the mesoderm of the gastrointestinal tract directly adjacent to the endoderm-derived epithelium. Homozygous null mice for Fkh6 showed postnatal growth retardation secondary to severe structural abnormalities of the stomach, duodenum, and jejunum. Dysregulation of epithelial cell proliferation in these organs resulted in an approximately fourfold increase in the number of dividing intestinal epithelial cells and marked expansion of the proliferative zone. As a consequence, the tissue architecture of the stomach and small intestine was distorted, with abnormal crypt structure, formation of mucin filled cysts, and lengthening of villi. Changes in the cellular phenotype and composition of the gastric and intestinal epithelia also suggests that epithelial cell-lineage allocation or differentiation may be affected by loss of Fkh6. From the analysis of a number of potential signaling molecules, we found Bmp2 and Bmp4 expression reduced in the gastrointestinal tract of Fkh6 mutant mice, suggesting that Fkh6 directs a signaling cascade that mediates communication between the mesenchyme and endoderm of the gut to regulate cell proliferation.

The mesenchymal winged helix transcription factor Fkh6 is required for the control of gastrointestinal proliferation and differentiation

The winged helix transcription factor Fkh6 is expressed in the mesoderm of the gastrointestinal tract directly adjacent to the endoderm-derived epithelium. Homozygous null mice for Fkh6 showed postnatal growth retardation secondary to severe structural abnormalities of the stomach, duodenum, and jejunum. Dysregulation of epithelial cell proliferation in these organs resulted in an approximately fourfold increase in the number of dividing intestinal epithelial cells and marked expansion of the proliferative zone. As a consequence, the tissue architecture of the stomach and small intestine was distorted, with abnormal crypt structure, formation of mucin filled cysts, and lengthening of villi. Changes in the cellular phenotype and composition of the gastric and intestinal epithelia also suggests that epithelial cell-lineage allocation or differentiation may be affected by loss of Fkh6. From the analysis of a number of potential signaling molecules, we found Bmp2 and Bmp4 expression reduced in the gastrointestinal tract of Fkh6 mutant mice, suggesting that Fkh6 directs a signaling cascade that mediates communication between the mesenchyme and endoderm of the gut to regulate cell proliferation.

Cervical esophageal web caused by an inlet patch of gastric mucosa

A 55-year-old woman had chronic, progressive dysphagia. An esophageal web in the cervical esophagus was identified by barium swallow and endoscopy. At endoscopy, an inlet patch of gastric mucosa was identified in proximity to the cervical web. It is believed that gastric acid production from the inlet patch led to development of the cervical esophageal web. We present our patient's case and review the literature relevant to this topic.

Dieulafoy's disease

Brisk bleeding from a Dieulafoy's gastric vascular anomaly is not an uncommon cause of upper gastrointestinal bleeding. The lesion in Dieulafoy's disease consists of a normal caliber artery that runs very close to the epithelial layers and is therefore relatively large compared with the vessels normally in that area. Meticulous inspection of the gastric mucosa, especially in the well-distended upper part of the stomach, is essential for an adequate diagnosis. Quite often multiple endoscopies are necessary before the lesion is recognized. In the past 10 years Dieulafoy's disease has also been described in almost every other part of the gastrointestinal tract, although less frequently than in the stomach. Endoscopy is the primary diagnostic technique but in some patients ES has been described to be of major help in identifying the vascular anomalies and in guiding local therapy aimed at occlusion of the abnormal vessel. Successful hemostasis has been reported with many different endoscopic techniques, with a success rate between 80% and 90% in expert hands. Alternatively, wedge resection or vascular ligation is required in cases of endoscopic failure at hemostasis. With further improvement of our diagnostic techniques, it is expected that even more patients will be diagnosed with Dieulafoy's disease in the future.

Alimentary tract duplications

A total of 17 patients with alimentary tract duplications underwent surgery at National Taiwan University Hospital from 1978 to 1994. Fifteen patients (88%) had gastrointestinal duplication and two (12%) had esophageal duplication. Common presenting symptoms of gastrointestinal duplication were melena and abdominal pain. The ileum was the most common site of duplication. Multiple duplications were seen in three patients. All duplications were cystic, except for one single appendiceal duplication. Ectopic gastric mucosa was detected in nine of the 16 nongastric duplications. One patient with ileal duplication had ectopic pancreatic tissue. Twelve patients received resection of the duplication with a segment of bowel and primary anastomosis, three patients underwent simple excision and two patients had partial resection of the duplication and stripping of the residual mucosa. Two patients had other associated congenital anomalies: one had ventricular septal defect and the other, imperforate anus and malrotation of intestine. There was no operative mortality or morbidity in this series.

Gastric gland heterotopia with extensive lymphoid stroma: a gastric lymphoepithelial cyst

Benign submucosal epithelial lesions of the stomach are rare. Their morphological aspect and pathogenesis and hence classification are unclear. The literature on this subject consists mainly of case reports describing lesions such as hamartomas, gastric gland heterotopia, duplication, submucosal cystic glands, gastritis cystica profunda, and adenomyoma. We report a patient presenting with a lymphoepithelial cyst, a lesion hitherto not yet described in the stomach. This lesion was an incidental finding in a surgical specimen from a patient during surgery for gastric adenocarcinoma. The cyst was submucosal, located at a distance from the tumor, and differs from classic "gastric gland heterotopia" by the presence of extensive lymphoid stroma.

Tracheal left mainstem bronchus and obstructive gastric mucosal intussusception associated with esophageal atresia

A tracheal left mainstem bronchus and gastric outlet obstruction owing to gastric mucosal intussusception occurred in a child who had esophageal atresia and tracheoesophageal fistula. Bronchography and bronchoscopy, indicated because of persisting atelectasis and ventilation dependency, showed a tracheal left mainstem bronchus. The atelectasis disappeared after reimplantation of the left mainstem bronchus into the carina. Feeding problems and recurrent pulmonary infections complicated the postoperative course. Radiographic imaging and esophagogastroscopy showed severe reflux esophagitis and a prepyloric mass that consisted of a gastric mucosal intussusception. Subsequent gastrotomy and resection of the intussuscepted mucosal fold relieved the gastric outlet obstruction. An antireflux procedure was performed simultaneously. The child recovered satisfactorily. It is suggested that gastric mucosal intussusception may be associated with esophageal atresia rather than with the presence of a gastrostomy tube, as has been proposed in the literature.

Antral diaphragm with achalasia cardia

A 50-year-old woman presented with gastric inlet and outlet obstruction due to achalasia cardia and antral mucosal diaphragm, respectively. The diagnosis was based on typical radiological features, endoscopy and full-thickness histology of biopsy at postmortem.

[Clinical pathology of gastric mucosal dysplasia]

The stomach cancer develops on dysplastic lesions of gastric mucosa. It can be found in every precancerous condition, as chronic gastritis, gastric adenoma, giant rugal hypertrophy, chronic peptic ulcer, gastric stump after partial resection, pernicious anaemia. So, this dysplastic change is not a specific lesion. Different classifications are known for grading of gastric dysplasia. Authors evaluated them compared with each other. The signs of dysplasia were studied in 306 gastric aimed biopsy specimens from 233 patients between 1979-1990. In this material severe dysplasia occurred in 20.6%. It means a frequency of 0.84% regarding all gastric endoscopies in the same period of time. The endoscopic investigation revealed a protruded lesion in 18.5% and excavated one in 45.9%. What is very important, local change could not be detected in 35.6%. Follow-up study could be performed in 49 patients in a period of 1-7 years. In this group cancer developed in five patients. By the other hand, 22 gastric carcinomas were proved amongst 233 patients. The authors' recommendation is to follow-up the patients bearing gastric dysplasia at least during 10 years after the diagnosis.

Epithelial dysplasia of the gastric mucosa. A morphometric and ploidy pattern study

60 cases of gastric dysplasia (20 mild, 20 moderate and 20 severe) were quantitatively studied and compared with cases of hyperplastic polyp (No 10), intestinal metaplasia (No 20), peptic ulcer (No 10) and invasive adenocarcinoma (No 20). In each case the area, the perimeter and the integrated optical density of 100 nuclei were measured in Feulgen stained tissue sections by means of a Leitz TAS. The stepwise discriminant analysis demonstrates that severe dysplasia and adenocarcinoma can be well distinguished from mild and moderate dysplasia. The ploidy pattern study demonstrates that the presence of severe dysplastic changes corresponds to a sharp increase in the degree of aneuploidy. In peptic ulcer, intermediate values between "benign" and "malignant" lesions were found.

Histochemical pattern in alimentary tract duplications of children

Detailed histological and histochemical studies using PAS, AB-PAS, and high-iron diamine-AB were done on 12 alimentary tract duplication cysts in children. Nine of these were thoracic and three were abdominal in location. A total of 11 cysts (nine thoracic and two abdominal cysts) were lined by gastric mucosa seen in varying stages of maturation. One triloculated cyst had, in addition, small intestinal mucosa and bronchial wall mucosa. One intra-mucosal rectal cyst was lined exclusively with primitive rectal mucosa. The cysts showed a variable pattern of mucin histochemistry. In three cysts, the gastric mucosa showed neutral mucins. In another three cysts, in addition to neutral mucins, focal positivity for sulphomucins was observed in the apical region of the surface epithelial cells. In the remaining five cysts, the gastric mucosa showed neutral mucins along with a variable mixture of sulpho- and sialomucins. A correlation was seen between mucin histochemistry and the age of the patient. Neutral mucins or focal positivity for sulphomucins was seen in patients aged 7 months or more, whereas a mixture of sulpho-, sialo-, and neutral mucins was identified in patients who were 1 month old, or less.

Ectopic gastric mucosa in the lower esophagus, presenting as a sessile polyp

A patient with dysphagia caused by a sessile polyp in the lower esophagus is reported. Histologic examination showed ectopic gastric mucosa. Of the benign tumors of the esophagus, only leiomyoma is seen regularly. The remaining tumors are so rare that the consequences of this diagnosis are unclear. When symptoms make treatment necessary, local excision is preferred.

Successful endoscopic transection of a partially obstructing antral diaphragm

A 14-yr-old girl presented with long-standing symptoms of partial gastric outlet obstruction due to an antral mucosal diaphragm that had a central aperture of 4-5 mm. The literature of this congenital malformation is reviewed with respect to diagnostic criteria and feasibility of endoscopic transection. The procedure and outcome of this first successful endoscopic transection of a partially obstructing antral diaphragm are reported.

Tubular duplication of the jejunum and ileum lined entirely by gastric mucosa

A 3-year-old boy who suffered from severe colicky abdominal pain is presented. Laboratory studies, including ultrasound, upper gastrointestinal films, and 99mTc-scan, were interpreted as normal. On exploration of the abdomen a tubular duplication of the small bowel was found. The duplication had a common mesentery with the normal bowel. By meticulous dissection the duplication was resected without interfering with the blood supply of the normal bowel. The entire duplication was found to be covered by gastric mucosa.

The radiographic and ultrasonographic evaluation of enteric duplication cysts

The pattern of diagnostic evaluation of seven children with duplication cysts of the gastrointestinal tract (two with bronchopulmonary foregut malformations and five with mid or hindgut duplications) is presented. Each child had plain radiographs followed by ultrasonic scans and appropriate confirmatory radiographic studies with contrast. Scans showed a well defined cystic mass in each case. Radiographs were able to identify more precisely the site of origin of the duplication cyst.

Hemorrhage from a Meckel's diverticulum: one case with heterotopic gastric mucosa treated with cimetidine

The first known use of the H2-receptor antagonist cimetidine (Tragamet) in a case of a Meckel's diverticulum containing heterotopic gastric mucosa with ileal ulcertaion and hemorrhage is reported. The interim use of cimetidine facilitated the performance of elective diverticulectomy for the indication of life-threatening hemorrhage.

Antral mucosal diaphragms in adults

A group of 53 patients with the diagnosis of antral mucosal diaphragm is reported. In over 50% of the cases the diaphragm was considered an asymptomatic lesion. In addition, an autopsy study in 29 unselected cases is reported with demonstration of five antral mucosal diaphragms in different forms. On the basis of these findings, it is evident that the antral mucosal diaphragm in the adult is not an acquired lesion secondary to peptic ulcer disease, but may be congenital. In addition, techniques of radiologic evaluation of the diaphragm for significant narrowing of the central aperture using the compressed barium tablet, and for significant gastric outlet obstruction using the "barium burger" examination, are described.

[Gastric polypoid heterotopy in the small intestine]

We present a 14 year old girl with a two years' history of colicky abdominal pain associated with the palpation of a tumor in the left upper quadrant of the abdomen. During these two years, the pain and the tumor appeared and disappeared spontaneously several times. In the operation we found a jejunojejunal intussusception, the head being a sessile polyp placed 20 cm from the ligament of Treitz. The pathological examination showed a polyp formed by mucosa similar to the gastric one with chief and parietal cells. We discuss the clinical pictures that can be associated with this pathological entity in this uncommon localization in opposition to the more common settling in Meckel's diverticulum.