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Gastroscopy image, diagnosis unknown. - Ärzteforum

Post#1 »

A 51 year old woman had an epigastric pain, partially relieved by omeprazole. At gastroscopy, the findings were minimal inflammation of the antrum, and mass lesions in the gastric fundus.

5 years ago, she had a similar pain, but had a normal gastroscopy. Her gall bladder was removed(cholelithiasis), but her pain returned within a year or two.

This week, the fundus had linear longitudinal rows of submucosal masses. There were about 150 of these, 0.5 to 1.0 cm, raised lesions, like chains of sub-mucosal pearls, along the ruggae. One was removed by a polypectomy snare, with electrocautery. Quick section pathology reports benign gastric mucosa. A biopsy test for Helicobacter pylori is negative.

I don't have a good atlas of gastric endoscopy, in this isolated town. Any advice would be welcome.

Would you consider posting this picture to your site?

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Lady Surgeon

Re: Gastroscopy image, diagnosis unknown. - Ärzteforum

Post#2 »

Nice way to look at pictures but it's no substitute for looking at it directly (markedly better resolution) and poking it with a biopsy forceps to get a "feel" of it. Similar looking things I've seen over the years are lymphomas, linitis plastica type of carcinomas, patchy areas of gastritis or chronic inflammation, and both adenomatous and hyperplastic mucosal changes. If permanent pathology comes back benign I wouldn't trust it and would rescope to do vigorous multiple biopsies.


Re: Gastroscopy image, diagnosis unknown. - Ärzteforum

Post#3 »

At repeat endoscopy her stomach looked the same: multiple linear strings of polyps, as seen in the picture.

These chains of polyps follow the lines of the ruggae of the stomach. Unlike typical adenomas, these were located in the proximal 2/3 of the stomach. The antrum is clear of polyps, and H. pylori negative, again.

We did snare polypectomies, removing 4 of the larger polyps. They were all about 1 or 1.3 cm diameter. It was difficult to retrieve the polyps, since the stomach peristalsis tends to sweep them distally. Electrocautery snare technique was employed, without other difficulty.

The pathology is benign adenomas.

Option 1: It is possible, but difficult to continue with endoscopic polypectomies. It will take a few hours to remove all of her polyps (possibly 100). And, I cannot be sure of retrieving all of these, so there is a risk of losing pathological information. Because of the risks of aspiration, and length of the procedure, an endotracheal tube would be required for such an effort. Could I just snare and drop these polyps in the stomach, allowing their digestion, losing specimens, while speeding the procedure?

Option 2: Subtotal, or near total gastrectomy, which seems extreme for benign disease. Should I anastamose esophagus to antrum, or a Roux limb?

Option 3: Surveillance gastroscopy every few months, removing any polyps that look larger, or atypical.

My other concern is for the mid and lower gut. Are studies of the jejunum and ileum required? A colonoscopy is planned.

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A Doctor

Re: Gastroscopy image, diagnosis unknown. - Ärzteforum

Post#4 »

I'd check on the pathology again, because a lot of the time regenerative gastric "adenomas" are inflammatory rather than neoplastic. I'd send the pathology "out" for another opinion. If these are truly multiple adenomas, in a good risk pt total gastrectomy may be indicated, particularly if these polyps (>100) are 1cm. or more in size. Finally, I don't think there are too many times to anastomose the esophagus to the antrum.....the leak rate is a bit higher (tension?), and reflux will be very problematic, plus if you are really serious about removing a premalignant organ, remove it. (Roux-en-y reconstruction) I've only had two cases but both had malignant degeneration in one of the polyps; one was 6cm and the other was l.5cm. Both alive and well 16 and 9 yrs postop.


Re: Gastroscopy image, diagnosis unknown. - Ärzteforum

Post#5 »

I agree with the advice to send out the pathology for another review. However, although tedious for the endoscopist, it seems preferable to me that as long as we're dealing with strict benign disease I would serially scope this patient and polypectomize away. What you can't snare, grab with a hot biopsy and destroy. A total gastrectomy can always be an option for dysplastic changes or frank carcinoma discovered. Perhaps I like to eat too much. Certainly the rest of her GI tract also needs evaluation.


Re: Gastroscopy image, diagnosis unknown. - Ärzteforum

Post#6 »

Have you ruled out Familial adenomatous polyposis,Familial juvenile polyposis or even Lynch's sindrome? All these conditions may develop gastric adenomas. If positive genetic studies, you can study the family and control them, detect early cancer, give genetic counseling etc.

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Treatment guru

Re: Gastroscopy image, diagnosis unknown. - Ärzteforum

Post#7 »

I have seen similar appearances in Peutz-Jeghers polyposis. The features of this condition include polyps (hamartomas) throughout the intestine, foregut, small and large bowel. Those in the duodenum may be easilly seen at OGD endoscopy as "plunging" polypi with long stalks. Colonic ones easilly seen with colonoscopy, often in their hundreds. Small bowel ones need a barium study.

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