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Indefinite-for-neoplasia is an expression used to describe lesions in which carcinoma or dysplasia cannot be clearly and conclusively established via biopsy. Gastric indefinite-for-neoplasia may represent a reactive change secondary to inflammation in some patients; however, some lesions are eventually diagnosed as dysplasia or carcinoma. Follow-up endoscopic biopsy is commonly performed in patients with gastric indefinite-for-neoplasia lesions. Nonetheless, patients may undergo resection based on a high index of clinical suspicion for dysplasia or carcinoma based on endoscopic findings. Accurate target biopsies of the lesion and effective communication with pathologists are required to improve diagnostic accuracy and avoid unnecessary re-examinations. It is important to establish endoscopic findings useful in differentiating lesions that require resection. In this review, we describe the approach for the management of indefinite-for-neoplasia lesions detected on gastric mucosal biopsy and the characteristics of lesions that require resection.
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Inflammatory pseudotumor (IPT) is a rare benign tumor of unknown etiology that can occur in almost any organ system. It has neoplastic features such as local recurrence, invasive growth, and vascular invasion, leading to the possibility of malignant sarcomatous changes. The clinical presentations of colonic IPT may include abdominal pain, anemia, a palpable mass, and intestinal obstruction. A few cases of colonic IPT have been reported, but colonic IPT with pedunculated morphology is very rare. Furthermore, since it can mimic malignant polyps, understanding the endoscopic findings of colonic IPT is important for proper treatment. Herein, we present a case of colonic IPT with pseudosarcomatous changes, presenting as a large polyp, mimicking a malignant polyp in the cecum, along with a literature review.
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Background/Aims@#Some sessile serrated lesions (SSLs) progress into dysplasia and colorectal cancer, however, the clinical and endoscopic characteristics of SSLs with dysplasia remain to be determined. In this study, we elucidated these characteristics in SSLs with dysplasia/carcinoma, compared with those of SSLs without dysplasia. @*Methods@#We retrospectively collected the clinical, endoscopic, and pathological data of 254 SSLs from 216 patients endoscopically resected between January 2009 and December 2020. @*Results@#All SSLs included 179 without dysplasia and 75 with dysplasia/carcinoma, including 55 with low-grade dysplasia, 10 with high-grade dysplasia, and 10 with submucosal cancer. In clinical characteristics, SSLs with dysplasia/carcinoma were significantly associated with advanced age, metabolic diseases, and high-risk adenomas. In endoscopic characteristics, SSLs with dysplasia/carcinoma were significantly associated with the distal colon, large size, polypoid morphology, surface-changes, no mucus cap, and narrow-band imaging international colorectal endoscopic classification (NICE) type 2/3. In the multivariate analysis, high-risk adenomas (odds ratio [OR], 2.98; p = 0.01), large size (OR, 1.18; p < 0.01), depression (OR, 11.74; p = 0.03), and NICE type 2/3 (OR, 14.97; p < 0.01) were significantly associated with SSLs with dysplasia/carcinoma. @*Conclusions@#SSLs had a higher risk of dysplasia in the distal colon than in the proximal colon. SSLs with large size, depression, and adenomatous surface-patterns, as well as those in patients with high-risk adenomas, increased the risk of dysplasia/ carcinoma. This suggests that the clinical and endoscopic characteristics can aid in the diagnosis and management of SSLs with dysplasia/carcinoma.
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Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. The diagnostic criteria for EoE have changed with our growing knowledge over the past two decades. Esophageal eosinophilia, which responds histologically to a proton pump inhibitor (PPI) is not a distinct disease but a subset of EoE. An endoscopic scoring system that relies on the assessment of exudates, rings, edema, furrows, and strictures is a useful tool for assessing endoscopic severity. PPIs are regarded as safe and effective first-line treatments for EoE. Oral topical corticosteroids or dietary therapy are also options for first-line treatment. Endoscopic dilation is effective for relieving the dysphagia symptoms of a patient with an esophageal stricture.
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Olmesartan, a recently introduced angiotensin II receptor blocker for hypertension, has been reported to cause drug-induced small bowel enteropathy. The diagnosis of olmesartan-associated enteropathy (OAE) needs clinical suspicion and the exclusion of coeliac disease, as it mimics coeliac sprue. Once diagnosed, it can be completely cured with the discontinuation of olmesartan. However, due to the extremely low incidence of OAE in Korea, clinical suspicion and diagnosis may be a challenge. The authors report the first case of OAE presenting with chronic diarrhea and acute kidney injury in Korea.
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Esophageal abscess caused by acute phlegmonous esophagitis is rare but life-threatening. Rapid abscess drainage is an important part of the treatment, and endoscope-assisted intra-luminal abscess drainage is frequently performed. Although endoscopic drainage is less invasive than surgery, it has the potential to cause esophageal stricture as a complication. We present a rare case of esophageal stricture as a complication of intra-luminal drainage and evaluate a method to minimize the incidence of esophageal stricture complications.
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Conventional endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been reported to be effective therapeutic options in sporadic non-ampullary duodenal tumors, but the rate of perforation is higher than that of other gastrointestinal lesions. Underwater EMR (UW EMR) has been reported to be a safe alternative to conventional EMR and ESD for superficial non-ampullary duodenal adenomas. We reviewed the medical chart and endoscopic report of patients who underwent endoscopic resection between August 2018 and February 2020. A total of 12 duodenal tumors were resected by UW EMR. The mean specimen and lesion sizes were 6.7 mm (2~16 mm) and 5.3 mm (2~10 mm), respectively. Of the 12 lesions, nine (75.0%) were located in the 2nd portion, and three (25.0%) were in the bulb. The mean procedural time was 7.8 minutes (3.2~18.7 minutes). Histologic results showed 10 dysplasia (nine low-grade, one high-grade) and two neuroendocrine tumors. UW EMR showed favorable efficacy and safety within small dysplastic lesions compared to previous studies’ results. Furthermore, it might be considered a treatment option with caution in patients with the duodenal subepithelial tumor within the third layer.
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Purpose@#Internal hernia after gastrectomy is a rare but potentially life-threatening condition without surgical intervention. Clinical risk factors of internal hernia should, hence, be reviewed after gastrectomy.From 2008 to 2018, patients who underwent gastrectomy for gastric cancer were investigated. @*Methods@#Abdominal computed tomography (CT) was used to screen for internal hernia, and surgical exploration was performed to confirm the diagnosis. Using retrospective statistical analysis, the incidence, characteristics, and risk factors were identified, and the characteristics of the internal hernia group were reviewed. @*Results@#The overall incidence of internal hernia was 0.9%. From statistical analysis, it was found that laparoscopic surgery was almost five times riskier than open gastrectomy (odds ratio [OR], 4.947; 95% confidence interval [CI], 1.308–18.710; p = 0.019). Body mass index < 25 kg/m2 (OR, 4.596; 95% CI, 1.056– 20.004; p = 0.042) and proximal gastrectomy (OR, 4.238; 95% CI, 1.072–16.751; p = 0.039) were also associated with internal hernia. Among 20 patients with internal hernia, 12 underwent laparotomy, and five had their bowels removed due to ischemia. All patients with bowel resected had suffered from short bowel syndrome. @*Conclusion@#Suspecting an internal hernia should be an important step when a patient with a history of laparoscopic gastrectomy visits for medical care. When suspected, emergent screening through CT scan and surgical intervention should be considered as soon as possible to prevent lifetime complications accordingly.
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Background/Aims@#The prediction of invasion depth is important to decide the treatment modality for undifferentiated-type early gastric cancer (EGC) less than 20 mm in size without ulceration. We aimed to identify the endoscopic features associated with submucosal invasion in undifferentiated-type EGC that meet the criteria of size and ulcer status. @*Methods@#A total of 120 patients with undifferentiated-type EGC who underwent endoscopic submucosal dissection (ESD) or gastrectomy between August 2008 and December 2017 were enrolled and reviewed retrospectively. All lesions met the ESD indications except for the invasion depth. We analyzed the endoscopic features of the tumors before resection and invasion depth after resection. @*Results@#There were 97 mucosal and 23 submucosal cancer lesions. Multivariable analysis revealed that the polypoid (OR, 90.8; 95% CI, 3.5~2,346.2) or elevated (OR, 5.0; 95% CI, 1.2~21.3) types, deep depression (OR, 76.0; 95% CI, 4.5~1,284.6), and upper (OR, 22.7; 95% CI, 3.0~170.8) or middle location (OR, 10.3; 95% CI, 1.9~55.4) were significant risk factors of submucosal invasion. @*Conclusions@#The treatment modality for undifferentiated-type EGC of the polypoid/elevated type or with deep depression located in the upper two-thirds of the stomach should be carefully considered, even if the tumor size and ulcer status meet the ESD indications.
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Purpose@#Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10–20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10–20 mm sized rectal NET and utilize them to decide upon the treatment strategy. @*Methods@#Twenty-eight patients with 10–20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (–) groups, and their respective data were analyzed. @*Results@#Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (–) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17–1,188.64; P=0.010). @*Conclusion@#Tumor grade 2 was the independent factor predicting LNM in 10–20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.
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Background/Aims@#The prediction of invasion depth is important to decide the treatment modality for undifferentiated-type early gastric cancer (EGC) less than 20 mm in size without ulceration. We aimed to identify the endoscopic features associated with submucosal invasion in undifferentiated-type EGC that meet the criteria of size and ulcer status. @*Methods@#A total of 120 patients with undifferentiated-type EGC who underwent endoscopic submucosal dissection (ESD) or gastrectomy between August 2008 and December 2017 were enrolled and reviewed retrospectively. All lesions met the ESD indications except for the invasion depth. We analyzed the endoscopic features of the tumors before resection and invasion depth after resection. @*Results@#There were 97 mucosal and 23 submucosal cancer lesions. Multivariable analysis revealed that the polypoid (OR, 90.8; 95% CI, 3.5~2,346.2) or elevated (OR, 5.0; 95% CI, 1.2~21.3) types, deep depression (OR, 76.0; 95% CI, 4.5~1,284.6), and upper (OR, 22.7; 95% CI, 3.0~170.8) or middle location (OR, 10.3; 95% CI, 1.9~55.4) were significant risk factors of submucosal invasion. @*Conclusions@#The treatment modality for undifferentiated-type EGC of the polypoid/elevated type or with deep depression located in the upper two-thirds of the stomach should be carefully considered, even if the tumor size and ulcer status meet the ESD indications.
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Purpose@#Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10–20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10–20 mm sized rectal NET and utilize them to decide upon the treatment strategy. @*Methods@#Twenty-eight patients with 10–20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (–) groups, and their respective data were analyzed. @*Results@#Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (–) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17–1,188.64; P=0.010). @*Conclusion@#Tumor grade 2 was the independent factor predicting LNM in 10–20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.
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Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder of hematopoietic stem cells characterized by chronic intravascular hemolysis, nocturnal hemoglobinuria, thromboembolic events and secondary bone marrow failure caused by uncontrolled complement activation. Generally, chronic abdominal pain and iron deficiency anemia are considered typical symptoms of gastrointestinal diseases, but are also common in PNH. We report a case of PNH presenting with chronic abdominal pain and iron deficiency anemia, along with a relevant literature review.
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Most upper gastrointestinal lipomas occur in the duodenal second portion, and gastric lipomas are rare. Most lipomas are usually asymptomatic, but symptoms such as abdominal pain, intussusception, ulceration, and intestinal obstruction may occur depending on the size and location and, rarely, can cause bleeding. Endoscopic polypectomy, endoscopic mucosal resection, and surgical resection are the treatments of choice for lipomas with intestinal obstruction or bleeding. Upper gastrointestinal bleeding from lipoma is mostly of duodenal origin and very rarely from the stomach. Here, we report a case of successful treatment of gastric lipoma with massive bleeding by endoscopic resection.
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Most upper gastrointestinal lipomas occur in the duodenal second portion, and gastric lipomas are rare. Most lipomas are usually asymptomatic, but symptoms such as abdominal pain, intussusception, ulceration, and intestinal obstruction may occur depending on the size and location and, rarely, can cause bleeding. Endoscopic polypectomy, endoscopic mucosal resection, and surgical resection are the treatments of choice for lipomas with intestinal obstruction or bleeding. Upper gastrointestinal bleeding from lipoma is mostly of duodenal origin and very rarely from the stomach. Here, we report a case of successful treatment of gastric lipoma with massive bleeding by endoscopic resection.
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PURPOSE: Postoperative complications (PCs) after gastrectomy are associated with readmission and longer hospital stay. This study aimed to determine the role of CRP as an early predictor of PCs and a reliable discharge indicator after gastrectomy. METHODS: Clinicopathologic data and PCs of 613 patients who underwent gastrectomy for gastric cancer in 2015–2016 were retrospectively analyzed, including consecutive blood samples for CRP obtained preoperatively, at the operative day, and postoperatively. Following the Clavien-Dindo classification, the patients were divided into a group with major PCs and a group with minor/no PCs. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Clinical factors related to major PCs were identified using univariate and multivariate logistic regression analyses. RESULTS: PCs occurred in 89 patients (14.5%). The most significant predictive factor for major PCs was a CRP concentration reduction rate of ≤38.1% (AUC, 0.82; sensitivity, 76.4%; specificity, 76.1%) between postoperative day (POD) 3 and 5 (R5), followed by ≤11.1% (AUC, 0.75; sensitivity, 73%; specificity, 76%) between POD 2 and 3 (R4). When both factors were applied (R4 ≤ 11.1% and R5 ≤ 38.1%), the specificity was 91.6%; when only one condition was satisfied (R4 ≤ 11.1% or R5 ≤ 38.1%), the sensitivity was 91%. CONCLUSION: CRP concentration reduction rates between POD 3 and 5 and between POD 2 and 3 were the best combination factors to predict PCs and indicate a safe discharge after gastrectomy for gastric cancer.
Subject(s)
Humans , C-Reactive Protein , Classification , Gastrectomy , Length of Stay , Logistic Models , Postoperative Complications , Retrospective Studies , ROC Curve , Sensitivity and Specificity , Stomach NeoplasmsABSTRACT
Peptic ulcer disease involves breakdown of the epithelial lining of the stomach or duodenum. Stenosis and associated gastric outlet obstruction is the least frequent complication of peptic ulcer disease. Most cases of stenosis occur because of duodenal or pyloric cannel ulceration. Although etiologies of peptic ulcer disease and the affected patient populations have changed, the most common etiologic factors remain Helicobacter pylori infection and use of non-steroidal anti-inflammatory drugs. In recent years, eradication of H. pylori and the use of proton pump inhibitors have reduced the incidence of complications. Because the predominant cause of gastric outlet obstruction has increasingly been attributed to malignant cancer in recent years, endoscopic examination is important to differentiate benign peptic stenosis from malignant stenosis. Medical treatment such as acid-reducing drugs or H. pylori eradication is the mainstay of treatment. Endoscopic dilation or surgical management may be considered in cases of refractory or recurrent stenosis despite medical treatment. Among the major complications of peptic ulcer disease, this report will provide an overview of peptic ulcer-related stenosis.
Subject(s)
Humans , Constriction, Pathologic , Dilatation , Duodenum , Endoscopy , Gastric Outlet Obstruction , Helicobacter pylori , Incidence , Peptic Ulcer , Proton Pump Inhibitors , Stomach , UlcerABSTRACT
Detection of early-stage gastric cancer improves the prognosis of patients. Endoscopic submucosal dissection (ESD) is a curative and stomach-preserving treatment for early gastric cancer (EGC) associated with a low risk of lymph node metastasis. However, several studies have reported missed diagnosis of gastric cancer. Therefore, endoscopists are required to learn accurate diagnostic skills to eliminate endoscopic blind spots. A systematic screening protocol to map the entire stomach without blind spots reduces the risk of missed lesions. Knowledge of the features of EGC or dysplasia is essential to identify suspicious lesion. Information of the common sites of occurrence of EGC can also enable a detailed endoscopic examination to improve detection rates. Previous reports investigating the location of gastric cancers resected by ESD or surgery showed that the antrum and lesser curvature of stomach were predominantly affected. Helicobacter pylori-induced atrophic changes advance from the antrum to the corpus along the lesser curvature, predominantly affecting these areas. Gastric cancers in the antrum and the lower corpus are also commonly missed during screening examination. Therefore, a careful examination of the lower third stomach is warranted to avoid missing synchronous and metachronous gastric lesions. Knowledge of the location of EGC enables accurate endoscopic examination and detection of EGC in early stage.
Subject(s)
Humans , Diagnosis , Endoscopy , Helicobacter , Lymph Nodes , Mass Screening , Neoplasm Metastasis , Optic Disk , Prognosis , Stomach , Stomach NeoplasmsABSTRACT
Follicular lymphoma is the most common form of low-grade B cell lymphoma. Follicular lymphoma occurs predominantly at lymph node sites and rarely in the gastrointestinal tract. Rare gastrointestinal follicular lymphoma is most commonly found in the small intestine, especially in the duodenum, and appears as multiple granules. However, gastric follicular lymphoma mostly appears as a subepithelial tumor. We observed two primary gastric follicular lymphomas that resembled subepithelial tumors located in the body of the stomach. Endoscopic ultrasound revealed hypoechoic lesions located in the submucosa layer. Since endoscopic forceps biopsies were inconclusive, we performed endoscopic submucosal dissection, which resulted in a final pathologic diagnosis of follicular lymphoma. Because of the indolent nature of gastrointestinal follicular lymphoma, the “watch and wait” strategy can be applied in the early phase. The identification of endoscopic characteristics of gastric follicular lymphoma can be helpful for differential diagnosis and decision of treatment strategy. Therefore, we report two cases of primary gastrointestinal follicular lymphoma diagnosed following endoscopic submucosal dissection.
Subject(s)
Biopsy , Diagnosis , Diagnosis, Differential , Duodenum , Gastrointestinal Tract , Intestine, Small , Lymph Nodes , Lymphoma, B-Cell , Lymphoma, Follicular , Stomach , Surgical Instruments , UltrasonographyABSTRACT
Duodenal perforation is a complication of endoscopic mucosal resection. Liver abscess secondary to iatrogenic perforation is extremely rare. A 43-year-old female visited the hospital to remove a sub-epithelial tumor on the duodenal bulb. After endoscopic mucosal resection with band ligation, duodenal perforation occurred. Endoscopic closure was performed successfully using a clipping device to manage duodenal perforation. After 4 weeks, the patient visited our outpatient clinic due to abdominal pain and fever. Abdominal computed tomography showed liver abscess that involved segment three. Liver abscess was resolved with a 10-week antibiotic treatment. To the best of our knowledge, no case of liver abscess secondary to duodenal perforation by endoscopic resection was reported to date in Korea. Here, we report a case of liver abscess caused by a duodenal perforation after endoscopic mucosal resection.