7175 Value of endoscopic ultrasound in the diagnosis and treatment of unusual gastrointestinal cystic lesions.

Abstract

Introduction /Aims: EUS is currently the best imaging modality to assess the nature of submucosal tumors of the gastrointestinal tract. The layer of origin of the tumor can be defined with unmatched precision, and discrimination between solid and cystic lesions can be accurately made. We assessed the value of EUS in the diagnosis and management of unusual gastrointestinal cystic lesions. Methods /Results: Esophageal bronchogenic cyst . A 46-year-old male patient was submitted to upper endoscopy for dyspeptic complaints, showing a submucosal tumor in the middle esophagus measuring 1.8 cm. CT could not detect the lesion. EUS demonstrated a cystic lesion in the submucosa layer of the esophagus, with anechoic content. Endoscopic needle aspiration of the cyst revealed a mucoid fluid. Biopsy of the cyst wall after needle knife incision showed respiratory type epithelium. Gastric duplication cyst . In a 66-year-old woman presenting with epigastric fullness, abdominal ultrasound detected a cystic lesion of uncertain origin, between the pancreas and the gastric wall. At upper endoscopy no submucosal bulging of the gastric wall was evident. EUS demonstrated a cystic lesion measuring 6.3 x 3.5 cm in the gastric wall, with anechoic content and inner septa, originating from the submucosa. EUS-guided puncture of the cyst using a linear array echoendoscope and a 22 G needle was performed and analysis of the aspirate fluid showed no malignant cells and normal CEA and CA 19-9 levels. A 3 cm incision with needle knife was performed and biopsy of the internal cyst wall revealed gastric columnar epithelium with no displasia. A small remnant cyst (1.7 cm) was seen on follow up EUS 4 weeks later. Duodenal duplication cyst . In a 53 year-old male presenting with vague epigastric disconfort, upper endoscopy showed a submucosal bulging lesion in the 2nd part of the duodenum, 2 cm above the major papila. EUS demonstrated a cystic lesion arising from the submucosa, and measuring 2.4 x 1.2 cm. The cyst content had some debris, and EUS guided aspiration produced a thick brownish fluid. Cytology analysis showed only inflammatory cells. Microbiological examination was negative. However, determination of CEA was 2360 ng/ml. Since the patient refused surgery, endoscopic cystotomy was performed. Biopsy of the cyst wall showed duodenal mucosa with no evidence of malignancy. Pneumatosis cystoides intestinalis . A 69-year-old male was admitted for rectal bleeding, diarrhea and lower abdominal pain. Colonoscopy showed multiple polyp-like bluish masses protruding into the lumen of the sigmoid and descending colon. Endoscopic Ultrasound showed submucosal gas-containing cystic lesions within the submucosa, confirming the diagnosis of PCI without the need to puncture the cysts. Conclusions: EUS was very useful in assessing submucosal cysts. The contents of the cyst could be displayed with great detail and analysis of aspirated fluid helped in therapeutic decisions.