Systematic review of giant gastric lipomas reported since 1980 and report of two new cases in a review of 117110 esophagogastroduodenoscopies.

AIM: To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative cases. METHODS: Literature systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywords: ("giant lipoma") AND ("gastric") OR [("lipoma") and ("gastric") and ("bleeding")]. Two authors independently reviewed literature, and decided by consensus which articles to incorporate. Computerized review of pathology/endoscopy records at William Beaumont Hospitals, Royal Oak and Troy, Michigan, January 2005-December 2015, revealed 2 giant gastric lipomas among 117110 consecutive esophagogastroduodenoscopies (EGDs), which were thoroughly reviewed, including re-review of original endoscopic photographs, radiologic images, and pathologic slides. RESULTS: Giant gastric lipomas are extremely rare: 32 cases reported since 1980, and 2 diagnosed among 117110 consecutive EGDs. Average patient age = 54.5 ± 17.0 years old (males = 22, females = 10). Maximal lipoma dimension averaged 7.9 cm ± 4.1 cm. Ulcerated mass occurred in 21 patients. Lipoma locations: antrum-17, body-and-antrum-4, antrum-intussuscepting-into-small-intestine-3, body-2, fundus-1, and unspecified-5. Intramural locations included submucosal-22, subserosal-2, and unspecified-8. Presentations included: acute upper gastrointestinal (UGI) bleeding-19, abdominal pain-5, nausea/vomiting-5, and asymptomatic-3. Symptoms among patients with UGI bleeding included: weakness/fatigue-6, abdominal pain-4, nausea/vomiting-4, early-satiety-3, dizziness-2, and other-1. Their hemoglobin on admission averaged 7.5 g/dL ± 2.8 g/dL. Patients with GI bleeding had significantly more frequently ulcers than other patients. EGD was extremely helpful diagnostically (n = 31 patients), based on characteristic endoscopic findings, including yellowish hue, well-demarcated margins, smooth overlying mucosa, and endoscopic cushion, tenting, or naked-fat signs. However, endoscopic mucosal biopsies were mostly non-diagnostic (11 of 12 non-diagnostic). Twenty (95%) of 21 abdominal CTs demonstrated characteristic findings of lipomas, including: well-circumscribed, submucosal, and homogeneous mass with attenuation of fat. Endoscopic-ultrasound showed characteristic findings in 4 (80%) of 5 cases: hyperechoic, well-localized, mass in gastric-wall-layer-3. Transabdominal ultrasound and UGI series were generally less helpful. All 32 patients underwent successful therapy without major complications or mortality, including: laparotomy and full-thickness gastric wall resection of tumor using various surgical reconstructions-26; laparotomy-and-enucleation-2; laparoscopic-transgastric-resection-2; endoscopic-mucosal-resection-1, and other-1. Two new illustrative patients are reported who presented with severe UGI bleeding from giant, ulcerated, gastric lipomas. CONCLUSION: This systematic review may help standardize the endoscopic and radiologic evaluation and therapy of patients with this syndrome.

Dose Uniformity of Topical Corticosteroids: A Simulated Trial of Fluorometholone Acetate 0.1% and Loteprednol Etabonate Gel 0.5.

PURPOSE: The purpose of the study was to determine the concentrations of Flarex® and Lotemax® when shaken and not shaken. Many patients fail to shake or inappropriately shake suspensions of corticosteroids before instillation as directed. This study was designed to help determine what concentration of corticosteroid these patients are receiving. In addition, independent confirmation of loteprednol etabonate ophthalmic gel dose uniformity was determined and compared as a possible alternative. METHODS: Drug concentrations of shaken versus unshaken Flarex and Lotemax were determined over a 20-day simulated tapered course in our institutional laboratory. Collected samples were analyzed by reversed-phase high-performance liquid chromatography with photodiode array detection at 240 nm. RESULTS: Flarex had a mean concentration of 93.7% of the declared concentration when shaken and 7.25% when not shaken. The difference between these groups was statistically significant (P = 0.0001). Lotemax had a mean concentration of 96.74% of the declared concentration when shaken and a mean concentration of 98.97% when not shaken. The difference between these groups was not statistically significant (P = 0.194). CONCLUSIONS: Flarex maintains dose uniformity when shaken. When not shaken, it has poor dose uniformity. Lotemax was consistent whether shaken or not in our study and can be considered to eliminate the variability of poor patient compliance with shaking. The manufacturers of both drugs recommend shaking before application.