Characteristic Endoscopic Features Research Articles

Saignement duodénal dû à une métastase d’un cancer pulmonaire contrôlé par radiothérapie : cas clinique et revue de la littérature

Gastrointestinal (GI) metastases in lung cancer rarely occur. We report here the case of a 43-year-old male active smoker who was admitted to our hospital for cough, abdominal pain and melena. Initial investigations revealed poorly differentiated adenocarcinoma of the superior-right lobe of the lung: positive for thyroid transcription factor-1 and negative for protein p40 and for antigen CD56, with peritoneal, adrenal and cerebral metastasis, as well as anemia requiring major transfusion support. Over 50% of cells were positive for PDL-1, and ALK gene rearrangement was detected. GI endoscopy showed a large ulcerated nodular lesion of the genu superius with active intermittent bleeding, as well as an undifferentiated carcinoma with positivity for CK AE1/AE3 and TTF-1, and negativity for CD117, corresponding to metastatic invasion originating from lung carcinoma. Palliative immunotherapy with pembrolizumab was proposed, followed by targeted therapy with brigatinib. Gastrointestinal bleeding was controlled with a single 8Gy dose of haemostatic radiotherapy. GI metastases are rare in lung cancer and present nonspecific symptoms and signs but no characteristic endoscopic features. GI bleeding is a common revelatory complication. Pathological and immunohistological findings are critical to diagnosis. Local treatment is usually guided by the occurrence of complications. In addition to surgery and systemic therapies, palliative radiotherapy may contribute to bleeding control. However, it must be used cautiously, given a present-day lack of evidence and the pronounced radiosensitivity of certain gastrointestinal tract segments.

Endoscopic Diagnosis of Eosinophilic Esophagitis: Basics and Recent Advances.

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease, characterized by esophageal dysfunction and intense eosinophil infiltration localized in the esophagus. In recent decades, EoE has become a growing concern as a major cause of dysphagia and food impaction in adolescents and adults. EoE is a clinicopathological disease for which the histological demonstration of esophageal eosinophilia is essential for diagnosis. Therefore, the recognition of the characteristic endoscopic features with subsequent biopsy are critical for early definitive diagnosis and treatment, in order to prevent complications. Accumulating reports have revealed that EoE has several non-specific characteristic endoscopic findings, such as rings, furrows, white exudates, stricture/narrowing, edema, and crepe-paper esophagus. These findings were recently unified under the EoE endoscopic reference score (EREFS), which has been widely used as an objective, standard measurement for endoscopic EoE assessment. However, the diagnostic consistency of those findings among endoscopists is still inadequate, leading to underdiagnosis or misdiagnosis. Some endoscopic findings suggestive of EoE, such as multiple polypoid lesions, caterpillar sign, ankylosaurus back sign, and tug sign/pull sign, will aid the diagnosis. In addition, image-enhanced endoscopy represented by narrow band imaging, endocytoscopy, and artificial intelligence are expected to render endoscopic diagnosis more efficient and less invasive. This review focuses on suggestions for endoscopic assessment and biopsy, including recent advances in optical technology which may improve the diagnosis of EoE.

Combination conventional endoscopy and endoscopic ultrasound can differentiate between esophageal granular cell tumors and leiomyomas.

Esophageal leiomyomas and granular cell tumors (GCTs) are the 2 most common subepithelial tumors found in the esophagus. We attempted to differentiate the 2 tumors using endoscopic findings and endoscopic ultrasound (EUS) features. Between December 2008 and June 2021, a total of 38 esophageal GCTs and 11 esophageal leiomyomas originating from the muscularis mucosa were selected. Clinical characteristics and endoscopic features were retrospectively reviewed. Although esophageal GCTs are mainly located in the lower third of the esophagus (81.6%), esophageal leiomyomas are mainly located in the upper third of the esophagus (45.5%). Broad-based (84.2%, P = .002) and whitish-to-yellowish color changes (97.4%, P < .001) are significant endoscopic features of esophageal GCTs. The echogenicity of esophageal leiomyoma was similar to that of proper muscle echogenicity. However, the echogenicity of esophageal GCTs was hyperechoic compared to that of the proper muscle layer (90.0% vs 9.1%, respectively, P < .001). EUS revealed a clearer hyperechoic epithelial lining in the esophageal leiomyoma than in esophageal GCTs (100% vs 26.7%, respectively, P < .001). The 5 endoscopic factors (location of the lower third, broad base, whitish-to-yellowish color, hyper-echogenic, and unclear demarcated hyperechoic epithelial line) were counted to differentiate esophageal GCTs from esophageal leiomyomas. Tumors with 3 or more endoscopic factors were all esophageal GCTs. The characteristic endoscopic and EUS features of esophageal GCTs were broad-based, whitish-to-yellowish colored subepithelial tumors located in the lower third of the esophagus and hyperechoic tumor with an unclear demarcated hyperechoic epithelial line. A combination of these features can predict esophageal GCTs before endoscopic resection.

S3463 Primary Intestinal Follicular Lymphoma

Introduction: Follicular Lymphoma (FL) mostly presents as a nodal lymphoma, however primary extranodal involvement is rare. The gastrointestinal tract is the most common site of extranodal FL, and with rates of FL increasing it remains important to recognize the characteristic endoscopic features of the disease. It typically carries an indolent course that may not even require treatment. We present a case of primary intestinal FL that involved the entire small intestine. Case Description/Methods: A 53-year-old Hispanic male with a history of gastrointestinal reflux disease (GERD), presented with refractory GERD symptoms despite maximal PPI therapy. An upper endoscopy was performed and revealed an irregular Z line, gastritis and numerous, patchy, small (< 1cm), white nodules in the second and third portion of the duodenum. Multiple biopsies were taken from the nodules. Pathology revealed Grade I-II FL. Capsule endoscopy was performed and revealed numerous similar lesions throughout the entire small intestine. He was referred to Oncology and underwent PET-CT scan which revealed multiple FDG-avid abdominopelvic lymph nodes. After discussion with Oncology, the patient elected for a watch and wait approach. Repeat PET-CT scan 6 months later revealed multiple abdominopelvic lymph nodes that are no longer FDG-avid. He remains asymptomatic and will be monitored closely off therapy. (Figure) Discussion: The most common primary intestinal lymphomas are diffuse large B-cell lymphoma (DLBCL) and mucosa associated lymphoid tissue (MALT) Lymphoma. FL only comprises approximately 1-2% of primary intestinal lymphomas. The small intestine is the most common location, with the second portion of the duodenum as the most likely site of involvement. It is rarely seen in the colon and stomach and there are no reported cases of esophageal involvement. Rates of diagnosis are on the rise, thus highlighting the importance of endoscopic recognition as it may often be seen in the second portion of the duodenum on routine upper endoscopy. Given the indolent course of FL, a watch and wait approach may be reasonable. Other options for therapy include chemotherapy, Rituximab, or radiation.Figure 1.: White nodular mass in duodenum visualized on capsule endoscopy consistent with patient's known diagnosis of Follicular Lymphoma.

Endoscopic features of isolated and traditional serrated adenoma-associated superficially serrated adenomas of the colorectum.

Superficially serrated adenoma (SuSA) is a recently proposed subtype of colorectal serrated lesions. It is characterized by distinct clinicopathological and molecular features, including mixed serrated and adenomatous histology and frequent genetic alterations involving KRAS and RSPO. This study aimed to characterize the endoscopic features of isolated and traditional serrated adenoma (TSA)-associated SuSAs. We retrospectively evaluated the endoscopic findings of 25 isolated SuSAs and 21 TSA-associated SuSAs that were histologically and molecularly characterized. SuSAs appeared as a sessile polyp or slightly elevated lesion located mostly in the sigmoid colon and rectum (88%). The size was between 3 and 20 mm (median, 6 mm). Most of them exhibited KRAS mutations (96%) and RSPO fusions/overexpression (92%). Endoscopically, many lesions had a whitish color (84%), a distinct border (96%), an irregular border (76%), and a lobulated surface (72%). However, diminutive lesions exhibited overlapping features with hyperplastic polyps. On narrow-band imaging, vessel patterns were invisible or appeared as lacy microvessels in most lesions (80%). Chromoendoscopy invariably showed stellar or elongated/branched stellar pits, indicating a serrated microarchitecture. Most TSA-associated SuSAs typically presented as polyps with a two-tier raised appearance, consisting of whitish lower and reddish higher components corresponding to a SuSA and a TSA, respectively. SuSAs exhibit several characteristic endoscopic features on white-light and image-enhanced endoscopy. Diminutive lesions exhibit endoscopic features overlapping with hyperplastic polyps. Nonetheless, the endoscopic diagnosis of larger and TSA-associated SuSAs may be feasible.

Detection of multiple intramucosal signet-ring cell carcinomas by white-light endoscopy and magnifying endoscopy with narrow-band imaging in a hereditary diffuse gastric cancer patient with a CDH1 germline mutation.

Detection of multiple intramucosal signet-ring cell carcinomas by white-light endoscopy and magnifying endoscopy with narrow-band imaging in a hereditary diffuse gastric cancer patient with a CDH1 germline mutation.

Characteristics and Early Diagnosis of Gastric Cancer Discovered after Helicobacter pylori Eradication.

The prevalence of gastric cancer after eradication (GCAE) is increasing dramatically in Japan. GCAE has characteristic features, and we must understand these features in endoscopic examinations. Differentiated cancer types were frequently found after eradication and included characteristic endoscopic features such as reddish depression (RD). However, benign RD can be difficult to distinguish from gastric cancer because of histological alterations in the surface structures (nonneoplastic epithelium or epithelium with low-grade atypia [ELA]) as well as multiple appearances of RD. Recently, we clarified similar alterations in genetic mutations between ELA and gastric cancer, suggesting that ELA is derived from gastric cancer. Clinically, submucosal invasive cancer was frequently found in patients after eradication therapy even if they received annual endoscopic surveillance. We can improve the diagnostic ability using image-enhanced endoscopy with magnified observation. (Gut Liver 2021;15:-345)

Endoscopic and clinicopathological characteristics of gastrointestinal adult T-cell leukemia/lymphoma.

Adult T-cell leukemia/lymphoma (ATLL) frequently involves the gastrointestinal (GI) tract, and patients mainly show an aggressive clinical course despite of intensive cytotoxic treatments. We investigated the characteristic clinicopathological and endoscopic features of GI ATLL. This was a retrospective analysis of 61 GI tract lesions in 54 ATLL patients. Thirty-six (67%) patients were classified as having lymphoma-type ATLL and 18 (33%) patients were classified as having acute-type with leukemic changes. Examined ATLL lesions in the stomach and intestine (small intestine and colorectum) were 40 (66%) and 21 (34%), respectively. Gastric ATLL lesions were frequently found in the lymphoma-type (29/38; 76%) compared with the acute-type lesions (11/23; 48%; P=0.023). Intestinal ATLL lesions were frequent in the acute-type (12/23; 52%) compared with the lymphoma-type lesions (9/38; 24%; P=0.023). Endoscopically, tumor-forming type lesions were significantly more frequent in lymphoma-type ATLL lesions (29/38 lesions; 76%) compared with acute-type lesions (10/23; 44%; P=0.0096). The superficial spreading-type was significantly more frequent in acute-type lesions (12/23 lesions; 52%) compared with lymphoma-type lesions (3/38; 8%; P=0.0003). Additionally, gastropathy-, enteropathy-, or proctocolitis-like lesions were distinct features, mainly in the acute type (9/23 lesions; 39%). Twenty three of 39 tumor-forming-type lesions (59%) were significantly composed of pleomorphic or anaplastic large cell lymphoma, and 13 of 15 superficial spreading-type lesions (87%) were significantly composed of pleomorphic medium-sized cells (P=0.007, in each). Six patients (11%) who were estimated as having primary GI ATLL based on restricted clinical stages, showed a significantly better overall survival (OS) compared with the 48 advanced-stage patients (P=0.017). Twenty patients with solitary tumor-forming-type lesions showed a significantly better OS than 17 patients with the multiple tumor-forming-type (P=0.015) and five with the mucosal-thickening-type lesions (P=0.04). Twenty-six patients with pleomorphic or anaplastic large cell ATLL showed a significantly better prognosis compared with 28 patients with pleomorphic medium-sized ATLL (P=0.034). ATLL predominantly involves the stomach. Leukemic behavior of ATLL had a large influence on the tumor location and endoscopic features of GI tract lesions. Gastropathy-, enteropathy-, and proctocolitis-like lesions showed additional distinct characteristics. Primary GI ATLL in the early clinical stages, solitary tumor-forming-type lesions and large tumor cells showed better prognostic factors than other factors, respectively.

Evidence‐based consensus on opportunistic infections in inflammatory bowel disease

Evidence‐based consensus on opportunistic infections in inflammatory bowel disease

Endoscopic findings of the gastric mucosa during long-term use of proton pump inhibitor – a multicenter study

Background and aim: It is clinically important to diagnose drug-induced gastric lesions correctly. Recently, the use of proton pump inhibitors (PPI) has increased worldwide. The histological features induced by PPI have been reported; however, few reports have described endoscopic findings induced by PPI. Therefore, we aimed to clarify the characteristic endoscopic features in PPI users and associated pathogenic factors.Methods: We prospectively registered 1007 consecutive participants (70 PPI users and 937 nonusers) who underwent endoscopic examination for cancer screening in three hospitals/clinics. Clinical data and endoscopic findings were recorded in the registration forms. We compared the endoscopic features between the two groups and evaluated contributing factors via univariate and multivariate analyses.Results: Multiple white elevated lesions (MWEL) and cobblestone-like mucosa (CLM) were more commonly observed in PPI users compared with nonusers (p < .01). Foveolar hyperplastic polyps were also frequently observed in PPI users but were not statistically significantly different (p = .06). MWEL and CLM were more frequently observed in older patients than in younger patients. MWEL was more frequently observed in female patients than in male patients; however, CLM was predominantly observed in male patients.Conclusion: MWEL and CLM are characteristic endoscopic features in PPI users. A gender-associated difference was noted in terms of the frequency of these lesions.

The Association Between CMV Viremia or Endoscopic Features and Histopathological Characteristics of CMV Colitis in Patients with Underlying Ulcerative Colitis

Cytomegalovirus (CMV) infection has been shown to be related to severe or steroid-refractory ulcerative colitis (UC) flare-ups. The aim of this study was to evaluate the endoscopic and pathological characteristics of CMV colitis in patients with UC and to assess the predictive value of the endoscopic and pathological features of CMV colitis. A total of 50 consecutive UC patients with CMV infection who were admitted to Peking Union Medical College Hospital from 2010 to 2015 were enrolled in this study. Twenty-five UC patients with CMV infection (50.0%) had concurrent CMV colitis. When the cutoff value was set at 1150 copies, the sensitivity and specificity of blood CMV DNAq polymerase chain reaction for predicting CMV colitis were 44.4% and 78.9%, respectively. A higher proportion of endoscopic punched-out ulcers, irregular ulcers, and cobblestone-like appearance were observed among the patients in the CMV colitis group than those in the non-CMV colitis group (52.0% versus 20.0%, 60.0% versus 16.0%, and 20.0% versus 0%, respectively, P < 0.05). The number of CMV inclusion bodies per high-power field was significantly higher in those with punch-out ulcerations (25.7% versus 60.0%, P < 0.05). A higher grade of pathological inflammation was observed in the CMV colitis group than in the control group (68.0% versus 44.0%). Characteristic endoscopic features with punch-out ulcers and high CMV viremia load may be useful for predicting the presence of CMV colitis in histology. Punch-out ulcers were found to be associated with a higher number of inclusion bodies on histology, suggesting a role of targeted biopsy for endoscopist.

Reversal Phenomenon on the Mucosal Borderline Relates to Development of Gastric Cancer after Successful Eradication of H. pylori

AIM: The characteristic endoscopic features of the gastric mucosa predictive of cancer development after successful eradication of H. Pylori have not been fully clarified. We have previously reported a reversal of red and white coloration in gastric corpus in some patients after eradication, and referred to it as the “reversal phenomenon on the mucosal borderline” (RP), which is often evident in patients who develop gastric cancer after eradication. Therefore we conducted a cross-sectional study to evaluate the correlation between RP and gastric cancer after H. Pylori eradication, and examined RP histologically. MATERIALS AND METHODS: Patients with a history of successful eradication who underwent esophago-gastro-duodenoscopy (EGD) in our hospital between November 2015 and January 2016 were prospectively enrolled. The numbers of newly diagnosed cancers in RP-positive and negative groups were assessed. In addition, both red and white areas in the RP-positive patients were scrutinized by narrow-band imaging with magnifying endoscopy (NBI-ME), and histologically assessed by taking biopsy specimens. RESULTS: Eighty-five patients were analyzed. Among them, 28 (32.9%) showed RP. Six cancers were found in the RP-positive group, and one in the RP-negative group (p<0.01). NBI-ME showed round pits without a light blue crest (LBC) in white areas, and round pits with LBC or villus-like structures with LBC or white opaque substance in red areas. All biopsy specimens from white areas had fundic glands, and all from red areas showed intestinal metaplasia. COCLUSION: Patients with RP tend to develop gastric cancer after eradication.

Gastric crypt dysplasia: a distinct subtype of gastric dysplasia with characteristic endoscopic features and immunophenotypic and biological anomalies.

Previous reports have shown that gastric epithelial dysplasia (GED) limited to the crypt (gastric crypt dysplasia, GCD) is commonly identified at the periphery of gastric carcinoma. However, it is unknown whether GCD is endoscopically identifiable, and how it relates to classic GED lesions. We investigated 1196 consecutive endoscopic resections of GED lesions between January 2011 and December 2014. We also evaluated clinicopathological features of these lesions, as well as the immunohistochemical expression of mucin (Muc)2, Muc5AC, Muc6, CD10, Ki67 and p53. We found 51 (4.3%) lesions composed microscopically of GCD among 1196 GED lesions. Those were elevated mucosal lesions (66.7%) similar in colour and texture to the adjacent mucosa (68.6%). GCD was likely to have an antropyloric location and a higher grade than the adenomatous type, similar to the foveolar and hybrid types (P < 0.05). A gastric immunophenotype was more common in GCD compared to adenomatous GED (P < 0.05). Ki-67- and p53-positive cells were more evident in GCD compared to the adjacent gastric mucosa. Our results demonstrated that GCD can be an endoscopically identifiable lesion, sharing many similarities with foveolar and hybrid GED, for which it may represent a precursor lesion in the gastric carcinogenic sequence.

Radiofrequency ablation therapy - the grave for GAVE (gastric antral vascular ectasia)?

Gastric antral vascular ectasia (GAVE) is a distinct acquired entity presenting with small ectatic vessels localized to the gastric antrum and having characteristic endoscopic features. GAVE can be observed in patients with cirrhosis with and without portal hypertension and also in other conditions such as autoimmune disorders, scleroderma, chronic renal failure, cardiac disease, following bone marrow transplantation, and in patients with a left ventricular assist device [1] [2] [3]. The pathophysiology of GAVE makes it a separate entity distinct from portal hypertensive gastropathy. Alterations in systemic blood flow, the role of local acting vasoactive substances such as nitric oxide, gastrin, and prostaglandin, and mechanical stress resulting from altered gastric antral motility are some of the proposed mechanisms.

26. Persistent microsphere-induced gastric ulceration after selective internal radiation therapy: a case report

Radioactive microsphere-based selective internal radiation therapy has emerged as an effective therapeutic modality for treatment of primary and secondary malignant liver tumours. However, a number of treatment-related complications have been described. This report describes a case of persistent pre-pyloric gastric ulceration in a 65 year old man with a history of recent selective internal radiation therapy for metastatic appendiceal adenocarcinoma to the liver. The patient was presented with epigastric abdominal pain after the radiation therapy. Two endoscopic examinations over the course of 4 months revealed a persistent gastric ulcer of maximum dimension of 30 mm in the pre-pyloric region. In both examinations, biopsies from the area showed reactive changes, inflammation and ulceration of surface epithelium. In addition, multiple symmetrical, uniform, round, purple, PAS positive spherules within the gastric mucosa and the lamina propria are identified. Their identical regular appearance suggested foreign material, which when correlated with the clinical history confirmed their nature as radio-microsphere used to treat hepatic malignancy. Previous cases of persistent microsphere-induced gastrointestinal ulceration have been described with potential life-threatening outcomes. Hence, both gastroenterologists and pathologists must be aware of this important complication, given its characteristic endoscopic and pathognomonic microscopic features.

A clinical study of tracheobronchopathia osteochondroplastica: findings from a large Chinese cohort.

Background and Study AimsTracheobronchopathia osteochondroplastica (TO) is an uncommon disease of the tracheobronchial system that leads to narrowing of the airway lumen from cartilaginous and/or osseous submucosal nodules. The aim of this study is to perform a detailed review of this rare disease in a large cohort of patients with TO proven by fiberoptic bronchoscopy from China.Patients and MethodsRetrospective chart review was performed on 41,600 patients who underwent bronchoscopy in the Department of Respiratory Medicine of Changhai Hospital between January 2005 and December 2012. Cases of TO were identified based on characteristic features during bronchoscopic examination.Results22 cases of bronchoscopic TO were identified. Among whom one-half were male and the mean age was 47.45±10.91 years old. The most frequent symptoms at presentation were chronic cough (n = 14) and increased sputum production (n = 10). Radiographic abnormalities were observed in 3/18 patients and findings on computed tomography consistent with TO such as beaded intraluminal calcifications and/or increased luminal thickenings were observed in 18/22 patients. Patients were classified into the following categories based on the severity of bronchoscopic findings: Stage I (n = 2), Stage II (n = 6) and Stage III (n = 14). The result that bronchoscopic improvement was observed in 2 patients administered with inhaled corticosteroids suggested that resolution of this disease is possible.ConclusionsTO is a benign disease with slow progression, which could be roughly divided into 3 stages on the basis of the characteristic endoscopic features and histopathologic findings. Chronic inflammation was thought to be more important than the other existing plausible hypotheses in the course of TO. Inhaled corticosteroids might have some impact on patients at Stage I/II.

Differential Diagnosis: EoE vs. PPI-Responsive Esophageal Eosinophilia

Eosinophilic esophagitis (EoE) is recognized by characteristic endoscopic features and histologic evidence of esophageal eosinophilia (≥15 eosinophils

EUS Findings of Gastric Ectopic Pancreas

Ectopic pancreas is a common subpithelial lesion in the stomach, but it is often difficult to differentiate ectopic pancreas from other mesenchymal tumors, such as gastrointestinal stromal tumors, due to nonspecific imaging findings. In this article the author demonstrates the characteristic endoscopic ultrasonography features of ectopic pancreas, which are potentially useful for differentiating ectopic pancreas from other mesenchymal tumors in the stomach. This article is part of an expert video encyclopedia.

Normal Small Bowel

Characteristic endoscopic features of the small bowel are circular Kerckring's folds, orange mucosa covered with villi, and active peristalsis. Between the duodenum and terminal ileum, up to 5 m of jejunum and ileum are interposed. Impressions from outside, small venectasias, lymphatic cysts, and lymphoid hyperplasia of the terminal ileum are considered variants of normal. This article is part of an expert video encyclopedia.

Detection of active bleeding from gastric antral vascular ectasia by capsule endoscopy

Gastric antral vascular ectasia (GAVE) has been recognized as one of the important causes of occult and obscure gastrointestinal bleeding. The diagnosis is typically made based on the characteristic endoscopic features, including longitudinal row of flat, reddish stripes radiating from the pylorus into the antrum that resemble the stripes on a watermelon. These appearances, however, can easily be misinterpreted as moderate to severe gastritis. Although it is believed that capsule endoscopy (CE) is not helpful for the study of the stomach with its large lumen, GAVE can be more likely to be detected at CE rather than conventional endoscopy. CE can be regarded as "physiologic" endoscopy, without the need for gastric inflation and subsequent compression of the vasculature. The blood flow of the ecstatic vessels may be diminished in an inflated stomach. Therefore, GAVE may be prominent in CE. We herein describe a case of active bleeding from GAVE detected by CE and would like to emphasize a possibility that CE can improve diagnostic yields for GAVE.