Stomach Flashcards
presented with worsening epigastric abdominal pain. He underwent an upper endoscopy, which showed a submucosal lesion in the gastric cardia as shown in FIGURE A. Subsequent endoscopic ultrasound (EUS) exam showed an intramural lesion arising from the muscularis propria measuring 35 mm x 28 mm. EUS-guided FNA [FIGURE B] showed a spindle cell tumor, positive for CD117 and DOG-1 on immunocytochemical assay. What is the next step in the management of this patient?
A. No further intervention or follow-up is needed.
B. Surveillance with EUS in 6 months to 1 year
C. Endoscopic snare resection
D. Surgical evaluation for excision
The majority of soft tissue tumors arising in the stomach are gastrointestinal stromal tumors (GISTs), followed by leiomyomas, and rarely, leiomyosarcomas. Both leiomyomas and gastric GISTs may be ≤0.5 cm or as large as 20 cm. Both tumors may grow both inwardly and outwardly to form a dumbbell shape, although leiomyomas are more likely to grow intraluminally (endogastric). In contrast, GISTs (and leiomyosarcomas) grow and expand in a predominantly extragastric fashion.
This case describes a GIST greater than 2 cm in size, confirmed with FNA and immunocytochemical assay. Followup management is thus required. Submucosal lesions <1 cm with EUS findings suggestive of benignity may be followed conservatively with EUS in 6 to 12 months, but would not be appropriate here due to the size of lesion. The management of lesions between 1 and 2 cm is controversial, with varied guidelines. Some clinicians will resect tumors between 0.5 and 1.0 cm in size by endoscopic snare resection. However, complete surgical resection is recommended for gastric GISTs >2 cm per NCCN guidelines due to risk or recurrence and metastatic spread, and would be the next best step for this patient.
A 36-year-old woman with past medical history of obesity, diabetes and heartburn develops dysphagia to solid foods. She undergoes an upper endoscopy which reveals a Schatzki ring with a moderate sized hiatal hernia and a small subepithelial lesion in the antrum. She is referred for endoscopic ultrasound of the subepithelial lesion [FIGURE]. What should be the management for this lesion?
A. Endoscopic mucosal resection
B. Endoscopic surveillance
C. Nothing further needed
D. Bite-on-bite biopsies
The lesion on EUS is arising from the third layer, which is the submucosa layer. It also appears hyperechoic. This is pathognomonic for a lipoma. Lipomas that are not causing symptoms and are incidentally found do not need any further management.
A 62-year-old woman with hypertension and hyperlipidemia presents 5 months after intragastric balloon (IGB) placement with the complaint of midepigastric abdominal pain. The pain is described as colicky, worse with oral intake, and associated with severe nausea. She had lost 30 lb over the preceding months by adhering to dietary guidelines however her oral intake is now limited by the new pain and nausea. The pain is worse after eating and she has been mostly drinking fluids. The pain began gradually approximately 3 weeks before her presentation and her food tolerance has gotten gradually worse. She denies any dark stools, green urine, or blood in the stool. The patient had been on twice daily high-dose proton pump inhibitor therapy with omeprazole since IGB placement. Physical exam revealed a palpable IGB in the left upper quadrant without rebound or guarding, unremarkable vital signs.
Laboratory test results:
Hemoglobin 13 g/dL (normal: 12-16 g/dL)
WBC 5,600/µL (normal: 3,500-10,500/µL)
Lipase 156.3 U/L (normal: <95 U/L)
Total bilirubin 0.4 mg/dL (normal: 0.3-1.2 mg/dL)
ALT 20 U/L (normal: 0-35 U/L)
AST 13 U/L (normal: 0-35 U/L)
Abdominal imaging is shown in FIGURES A and B. What is the most likely diagnosis?
A. Gastroesophageal reflux secondary to gastric balloon
B. Intragastric balloon deflation with small bowel obstruction and air fluid levels
C. Dietary noncompliance leading to late post-placement nausea and vomiting
D. Balloon hyperinflation causing intermittent gastric obstruction symptoms
3/14
- Chest x-ray revealed intact balloon located in the stomach with a large air bubble. Intragastric balloon hyperinflation with an air bubble was noted and the balloon was removed endoscopically.
- Follow-up evaluation 3 months later revealed normalization of the serum lipase and resolution of the pain, confirming balloon hyperinflation causing intermittent gastric obstruction symptoms.
- Balloon hyperinflation has recently been described as a rare complication of saline-filled IGBs. It could lead to compression of surrounding organs including the pancreas.
- Antacid therapy may be associated with IGB bacterial and fungal overgrowth that could lead to overgrowth of gas-forming organisms inside the gastric balloon.
A 65-year-old man is referred to you for postprandial epigastric discomfort of 6 months’ duration. He denies nausea, vomiting, hematemesis, or weight loss. His past medical history includes coronary artery disease with revascularization 3 years ago, remote cholecystectomy, and a 25-year smoking history. His medications include lansoprazole 30 mg qd and aspirin 81 mg qd.
Endoscopy reveals a normal esophagus and duodenum. A 1.2-cm semi-pedunculated polyp is noted in the upper body. The duodenum is normal. What would you do next?
A. Obtain biopsies to determine the polyp histology and follow-up plan.
B. Prescribe H. pylori eradication, with follow-up endoscopy in 3 months.
C. Proceed with snare polypectomy.
D. Schedule endoscopic ultrasound.
E. Probable fundic gland polyp, reassure patient.
Guidelines on mucosal tissue sampling for gastric polyps recommend complete polypectomy for solitary polyps according to size - specifically, for sporadic fundic gland polyps (FGP) >10 mm, hyperplastic polyps >5 mm, and all adenomatous polyps. In the setting of multiple polyps, the guidelines advise the largest polyp be resected entirely, and a set of sampling biopsies should be obtained from the smaller polyps.
A 48-year-old Hispanic man is referred to you for upper endoscopy for intermittent dyspepsia of 9 months’ duration. He describes a burning sensation in the epigastrium on most days. He has received empiric treatments with a PPI for 2 months as well as H. pylori eradication therapy. His past medical history includes hypertension, diabetes, and NAFLD. His family history is unremarkable. He emigrated from the state of Chiapas in southern Mexico at the age of 38.
Endoscopy reveals a normal esophagus and duodenum. The antrum is noted to be erythematous without nodularity, with inconclusive NBI visualization. The stomach has normal insufflation. What would you do next?
A. Biopsies for rapid urease testing to determine if H. pylori therapy has been effective.
B. Obtain non-targeted biopsies from the antrum, incisura, and corpus.
C. Nutrition consult and hepatology referral for NAFLD.
D. Reassurance with clinic follow-up in 6 months.
- Symptomatic patients at intermediate to high risk of gastric cancer should undergo nontargeted biopsy mapping of the stomach at the time of the index endoscopy, along with targeted biopsies of mucosal abnormalities.
- Higher risk patients include those with a family history of gastric cancer, as well as foreign-born individuals who emigrate from high incidence regions (e.g., southern Mexico). Careful inspection of the stomach is warranted, including adequate insufflation to rule out intramural abnormalities such as linitis plastica. Biopsy mapping of the stomach will help determine if the patient has premalignant lesions (atrophy, gastric intestinal metaplasia - GIM).
- Current literature and guidelines suggest that a surveillance endoscopy in 2-3 years may be warranted in subjects with higher risk mucosal assessment, including extensive intestinal metaplasia (GIM in antrum and body) or stage 3 or 4 OLGA scoring.
A 45-year-old woman with a 30-year history of type 1 diabetes mellitus has retinopathy, neuropathy in her fingers and toes, and nephropathy. She presents with 6 months of frequent nausea, early postprandial fullness, and bloating, but rare vomiting. She has lost 5 lb in the last 6 months. Examination confirms loss of sensation in toes, absent pupillary reaction to light, and a succussion splash in the abdomen. Her diabetes is controlled with insulin, and she additionally takes a baby aspirin daily for cardiovascular protection. Which of the following is the best next step?
A. CT abdomen
B. Upper GI endoscopy
C. Gastric scintigraphy
D. Abdominal ultrasound
E. Lactulose breath test
- The history is highly suggestive of the development of gastroparesis in a patient who is predisposed because of long-standing diabetes with end-organ damage.
- The lack of sinus arrhythmia is a clue to the presence of vagal neuropathy affecting the heart, and that is associated with abdominal vagal dysfunction since the vagus is a long nerve and diabetes causes dysfunction distally before extending proximally.
- Therefore, if the cardiac vagal branches are affected, it is likely that the abdominal vagus also is dysfunctioning. However, the diagnosis of gastroparesis is based on the combination of symptoms of gastroparesis, absence of gastric outlet obstruction or ulceration, and delay in gastric emptying.
- This patient takes a baby aspirin, and peptic ulcer disease causing gastric outlet obstruction is certainly possible, and needs to be ruled out before proceeding with gastric scintigraphy, based on guideline recommendations.
- Therefore, an upper endoscopy is warranted before any other tests to look for gastroparesis.
- Scintigraphy over 4 hours with a solid meal is the standard diagnostic test for gastroparesis, while wireless capsule motility testing and labeled carbon breath tests are considered alternatives.
- CT scanning or ultrasound imaging are not warranted at this time, and lactulose breath testing is used for small intestinal bacterial overgrowth, not gastroparesis.
The patient in the previous question undergoes an EGD, which is normal other than some mild gastritis, followed by a gastric scintigraphy that shows 55% of the egg meal retained in the stomach at 4 hours. What is the best next step?
A. Advise on frequent, small volume, low-residue meals combined with antiemetic therapy.
B. Start nortriptyline.
C. Refer patient for gastric peroral endoscopic myotomy (G-POEM).
D. Prescribe aprepitant.
E. Refer patient for gastric electrical stimulator (GES).
The first-line management of diabetic gastroparesis should be based on dietary modifications, symptom control with antiemetics, and reserving prokinetic therapy for those who fail conservative measures. Standard antihistamines or 5-HT3 receptor antagonists such as ondansetron are first-line antiemetics. Metoclopramide may be prescribed at doses not exceeding 40 mg/day to avoid galactorrhoea, anxiety, or involuntary movements, and use beyond 12 weeks is associated with increased risk of tardive dyskinesia. Nortriptyline may not be well tolerated in a patient who already has delayed gastric emptying. Interventions such as G-POEM and GES are premature in this patient who has yet to receive first-line therapy. Aprepitant is typically used only for “rescue” therapy for 3 days, and insurance approval for a prescription can be difficult.
A 25-year-old man underwent an upper endoscopy for the evaluation of chronic abdominal pain. Biopsies of the stomach and duodenum demonstrate >50 eosinophils per high-power field. A CBC shows an elevated peripheral eosinophil count. Which of the following treatment options would you recommend for long-term remission?
A. An anti-IL-5 agent
B. An anti-IgE agent
C. Systemic steroids
D. Specialized diet
- This is a patient with eosinophilic gastroenteritis (EGE), a rare inflammatory gastrointestinal disorder. There are several proposed management options, although most have not been studied extensively due to the rarity of this condition.
- Specialized diets are one of the most effective treatment options, and include an elemental diet that can induce remission in the majority of patients with EGE.
- A 6-food elimination diet is easier to adhere to and may be effective as well for maintenance. Systemic steroids are also effective at induction, but should be tapered after 6-8 weeks and would not be a good option for long-term treatment due to side effects.
- Studies with biologic agents have yielded suboptimal results. Mepolizumab, an anti-IL 5 agent, improved tissue eosinophilia but did not have significant improvement in clinical symptoms.
- Similarly, omalizumab, an anti-IgE drug, can reduce tissue eosinophilia but do not work as well as specialized diets in EGE.
A 53-year-old Asian man is referred to you for postprandial epigastric discomfort of 5 months’ duration. He denies nausea, vomiting, hematemesis, or weight loss. His past medical history is unremarkable. He is currently not on prescribed medications, but notes use of 2 different herbal supplements.
Endoscopy reveals a normal esophagus and duodenum. The stomach examination reveals a shallow 8-mm erosion of the incisura which is biopsied. Histology reveals moderate atrophy of the antrum and corpus, without evidence of H. pylori infection. Low-grade dysplasia (LGD) is present at the incisura site and is confirmed by a by a second pathologist. What would you do next?
A. Perform EUS.
B. Schedule surveillance endoscopy in 6-12 months.
C. Plan for EMR of the incisura lesion.
D. Check H. pylori ELISA serology.
- Gastric low-grade dysplasia (LGD) in a visible lesion may be appropriate for resection by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), depending on local availability.
- Forceps biopsies have modest sensitivity. The histological diagnosis of low-grade dysplasia may be upgraded to a diagnosis of high-grade dysplasia or adenocarcinoma after EMR or ESD.
- Surveillance endoscopy within 12 months is also reasonable, particularly if this is the patient’s preference.
A 64-year-old woman is referred to you for early satiety of 4 months’ duration. She denies nausea, vomiting, or hematemesis. Her past medical history includes coronary artery disease with revascularization, hypertension, and COPD. Her medications include omeprazole, aspirin, and atorvastatin. The CBC, metabolic panel, and liver function tests are normal.
Endoscopy reveals a normal esophagus and duodenum. The antrum demonstrates atrophic features. The NBI exam of the esophagus and stomach are unremarkable. Histology confirms mild atrophy of the antrum and normal corpus. What would you do next?
A. Repeat EGD in 3 months with repeat biopsies to rule out dysplasia.
B. Nutrition consult for early satiety.
C. Reassurance, with primary care follow-up.
D. Surveillance EGD in 3 years for a premalignant lesion.
- Reassurance is indicated, as the EGD with biopsies of the antrum and corpus have identified mild atrophy isolated to the antrum, a low risk lesion, which does not require endoscopic surveillance, particularly with the patient’s co-morbidities.
- Biopsy mapping of the stomach, with non-targeted biopsies of the antrum, incisura, and corpus will help determine if the patient has significant premalignant lesions (severe atrophy, extensive gastric intestinal metaplasia).
- In this case, while the patient may not have had formal biopsy mapping (e.g., incisura biopsies with OLGA scoring), the visual inspection, NBI exam, and histology are reassuring.
A 55-year-old Asian man undergoes upper endoscopy for evaluation of chronic heartburn. The esophagus is normal, but there is mucosal atrophy in the body of the stomach. Biopsies of the atrophic area reveal intestinal metaplasia. Which is the most important next step in management?
A. Radiofrequency ablation of the antrum (barretts esog, not GIM)
B. Urea breath test
C. Proton pump inhibitor daily (no data)
D. Vitamin C 750 mg per day (no data)
- pt w/ intestinal metaplasia of the stomach - risk factor for gastric cancer
- 1st step GIM- evaluate for and eradicate H. pylori, if present, as eradication may slow progression to cancer
52AA male with refractory GERD- daily postprandial GERD and epigastric discomfort and nocturnal awakening. He has not responded to twice daily PPI. He has not had esophageal pH or impedance testing. PMH childhood asthma, remote cholecystectomy, and hyperlipidemia. His medications include omeprazole and simvastatin. His brother was recently diagnosed with pancreatic cancer, and his mother died from gastric cancer. His physical exam is unremarkable, notable for a BMI of 32.0. The CBC and liver function tests are normal. EGD- normal esophagus, stomach, and duodenum, including the NBI exam of the esophagus and stomach. What would you do next?
A. Proceed with esophageal pH capsule placement.
B. Reassure the patient, and plan for taper of PPI therapy.
C. Acquire biopsies for histology from the antrum, incisura, and body.
D. Proceed with abdominal CT with pancreatic protocol.
E. Obtain samples from the antrum and body for rapid urease testing for H. pylori.
- Patients at intermediate to high risk of gastric cancer should undergo nontargeted biopsy mapping of the stomach at the time of the index endoscopy, along with targeted biopsies of mucosal abnormalities.
- Higher risk patients include those with a family history of gastric cancer. Careful inspection of the stomach is warranted, including adequate insufflation to rule out intramural abnormalities, including linitis plastica.
- Biopsy mapping of the stomach will help determine if the patient has premalignant lesions (atrophy, gastric intestinal metaplasia - GIM)
- surveillance endoscopy in 2-3 years in subjects with higher risk mucosal assessment, including extensive intestinal metaplasia (GIM in antrum and body) or stage 3 or 4 OLGA scoring.
