Dilated Glands Research Articles

Pediatric Chalazion Case Report

Background and Objectives
 A chalazion, also known as a stye, is a common and chronic inflammatory problem of the eyelids where one or more Meibomian glands are blocked. Previous studies have shown that a chalazion is a sign of Meibomian Gland Dysfunction (MGD) and evaporative dry eye disease. The prevalence of chalazia in the pediatric population has recently been noted. In this report, we will describe two pediatric cases of chalazion that are associated with MGD and related dry eye disease. 
 Methods
 This is a case report of non-genetically related 7-year-old and 16-year-old patients as they were each seen for newly developed chalazia.
 Results
 External exam in both patients showed chalazia, waxy plugs and poor Meibomian gland expression. Meibography showed shorten, truncated, and dilated Meibomian glands with rapid tear break-up times leading to the diagnosis of evaporative dry eye disease due to MGD.
 Conclusion
 These cases serve to confirm an increase in the prevalence of MGD in the pediatric population and to emphasize the need for early screening for dry eye disease. 
 Key Words: Chalazion - Meibomian gland dysfunction - Pediatric Dry Eye Disease

PIN-like (Ductal) Adenocarcinoma of the Prostate.

Prostatic intraepithelial neoplasia like (PIN-like ductal) carcinoma are rare tumors characterized by crowded, often cystically dilated glands architecturally resembling high-grade prostatic intraepithelial neoplasia, lined by malignant pseudostratified columnar epithelium. The largest prior series studied 9 radical prostatectomies (RPs) and suggested a behavior similar to Gleason score 6. We sought to investigate this rare tumor within a larger series. PIN-like carcinoma cases were identified from in-house and consultation files from 2008 to 2017. A total of 190 total cases were identified (in-house cases n=8, 4.2%, consult cases n=182, 95.8%); the diagnosis of PIN-like carcinoma was made on needle biopsy (n=181), transurethral resection (n=5) and RP (n=4). The average age was 70 years. The average number of cores with involvement by PIN-like carcinoma was 2 (1 to 12). The average maximum percentage by a PIN-like carcinoma component of any core was 43.5% (5% to 90%). In 58/181 (32.0%) biopsy cases, due to selective parts having been submitted for consultation, it was unknown whether there was an association with acinar carcinoma. A total of 72 cases showed exclusively PIN-like carcinoma. Highest grade groups (GGs) on biopsies with known acinar or papillary/cribriform ductal carcinomas were GG1 (n=23, 45.1%), GG2 (n=14, 27.5%), GG3 (n=9, 17.6%), GG4 (n=4, 7.8%), and GG5 (n=1, 2.0%). Of 44 cases where the patient would be considered eligible for active surveillance, 18 (41.0%) underwent RP. RP slides were available in 16 cases; 3 (18.8%) cases diagnosed on biopsy did not show PIN-like carcinoma on review of RP slides. PIN-like carcinoma was present without an associated acinar tumor in 3 (23.1%) RPs; 2 showing tumors with large, cystic dilated glands extending into periprostatic tissue. In 7/13 cases (53.8%), the acinar component was the dominant tumor and the PIN-like carcinoma component was small (<1 cm). The overall grade at RP was GG1 (5/13, 38.5%) and GG2 (8/13, 61.5%). In all cases with an acinar component, the acinar tumor was anatomically distinct from the PIN-like carcinoma tumor. The GGs of the separate acinar tumors were GG1 (6/10) and GG2 (4/10) with percent pattern 4 ≤5% in all 4 cases. No cases were associated with metastases to lymph nodes or seminal vesicle invasion. Extraprostatic extension was present in 6/13 (46.1%) cases, from the acinar component in 1 (7.7%) case and the PIN-like carcinoma component in 5 (83.3%) cases. In all 5 cases, there was a peculiar morphology of thin papillary projections into cystic dilated PIN-like carcinoma glands. Immunohistochemical expression of ERG was positive in 1/11 (9.1%) case. 1/11 (9.1%) case showed heterogeneous loss of PTEN. Overall, PIN-like carcinoma tumors are limited in size, not advanced in stage, not associated with high-grade cancer on RP, and show low rates of Gleason pattern 4 and TMPS-ERG rearrangement. Our study supports grading classic PIN-like carcinoma as Gleason pattern 3; at the current time we recommend grading thin papillary projections of PIN-like carcinoma as pattern 4. Longer term studies will be needed to determine the clinical significance of thin papillary projections in PIN-like carcinoma.

Magnified Endoscopic Findings of Multiple White Flat Lesions: A New Subtype of Gastric Hyperplastic Polyps in the Stomach

Background/Aims:While the occurrence of multiple whitish flat elevated lesions (MWFL) was first reported in 2007, no studies on MWFL have been published to date. The present retrospective observational study aimed to clarify the endoscopic findings and clinicopathological features of MWFL. Methods:Subjects were consecutive patients who underwent upper gastrointestinal endoscopy as part of routine screening between April 2014 and March 2015. The conventional white-light, non-magnifying and magnifying narrow-band images were reviewed. Clinical features were compared between patients with and without MWFL. Results:The conventional endoscopic findings of MWFL include multiple whitish, flat, and slightly elevated lesions of various sizes, mainly located in the gastric body and fundus. Narrow-band imaging enhanced the contrast of MWFL and background mucosa, and magnifying narrow-band imaging depicted a uniformly long, narrow, and elliptical marginal crypt epithelium with an unclear microvascular pattern. Histopathological findings revealed hyperplastic changes of the foveolar epithelium, and parietal cell protrusions and oxyntic gland dilatations were observed in the fundic glands, without any intestinal metaplasia. The rate of acid-reducing drug use was significantly higher in patients with MWFL than in those without (100% [13/13] vs. 53.7% [88/164], p<0.001). Conclusions:The present study indicated a relationship between the presence and endoscopic features of MWFL and history of acidreducing drug use.

AIUM-ACR-SPR-SRU Practice Parameter for the Performance and Interpretation of a Diagnostic Ultrasound Examination of the Extracranial Head and Neck.

AIUM-ACR-SPR-SRU Practice Parameter for the Performance and Interpretation of a Diagnostic Ultrasound Examination of the Extracranial Head and Neck.

A huge lacrimal gland ductule dacryolith with a hairy nucleus: a case report

BackgroundDacryoliths in lacrimal gland ductule are a rare condition and an unusual cause of conjunctivitis. Here we report a case with a large lacrimal gland ductule stone with an unique hairy nucleus.Case presentationA 38-year-old female presented with a red left eye for one month. Physical examination revealed an inflammatory granuloma in the lateral canthus and a fistula with purulent secretion. Antibiotics did not ameliorate the symptoms. After we incised the fistula, a huge dacryolith (10 mm × 5 mm × 3 mm) was identified at the end of the dilated lacrimal gland ductule and was removed surgically. Histopathologic examination showed a hairy nucleus surrounded by lamellar structure. The symptoms were resolved in 2 weeks after dacryolith extraction. The formation of the hair-centered dacryolith might be associated with the patient’s personal history of being a rabbit raiser for years.ConclusionWe should be aware of lacrimal gland ductule dacryolith as a rare cause of conjunctivitis. The relationship between dacryolithiasis and fur-bearing animal raising warrants further investigation.

Chronic inflammatory and degenerative endometrial lesions in subfertile Criollo Limonero cattle; a B. taurus Latin-American breed threatened with extinction; A case-control study

Criollo Limonero is a tropical Bos taurus breed for sustainable dual purpose (milk and beef) production in the South-American tropics, which is currently threatened with extinction. The objective was to perform a clinical evaluation and histopathological assessment of uterine biopsy samples of repeat breeder (RB) Criollo Limonero cattle to determine the occurrence of pathological conditions as potential causes of subfertility. Twenty-four Criollo Limonero cattle [18 cows (5–13 years old) and 6 heifers (6–7.5 years old)] that had failed to conceive after four or more services were considered for this study. Additionally, five cows with history of adequate reproductive performance were used as a control group. Animals were submitted to physical exam, vaginoscopy, and ultrasonographical evaluation of the reproductive tract. Uterine biopsy samples were collected for histopathological evaluation. Vaginoscopy revealed that 41.7% of the RB cattle had abnormal vaginal secretions, while abnormal secretions were not observed in any control cow. Ultrasonographical examination of the uterus revealed the presence of free uterine fluid in 20.8% of the RB animals, while none of the control cows had fluid in the uterine lumen. In addition, ovarian cysts were observed in 25.0% of the RB animals. Histopathological evaluation of the endometrial biopsies revealed that mononuclear leukocyte infiltration, dilated uterine glands, and periglandular fibrosis were the most prevalent lesions in the sub-fertile animals. Chronic endometritis characterized by inflammatory (mononuclear leukocyte infiltration) and degenerative (dilated glands and periglandular fibrosis) endometrial lesions, and ovarian cysts were the most frequent reproductive pathologies observed in the studied subfertile Criollo Limonero cattle, suggesting a strong association with their reduced fertility.

Sub-chronic toxicity of Gyejibokryeong-hwan in Sprague-Dawley rats

Ethnopharmacological relevanceTraditional herbal formula Gyejibokryeong-hwan (GJBRH; Guizhifuling-wan, Keishibukuryo-gan) consisting five medicinal herbs has been used to treat uterine disorders, gynecological diseases and blood stasis syndrome in Asia. Aim of the studyWe evaluated the safety of GJBRH in Crl:CD Sprague-Dawley (SD) rats over a period of 13 weeks. Materials and methodsTo confirm the stability of the components of GJBRH, we analyzed the component contents in GJBRH at different storage periods, using high-performance liquid chromatography. Male and female SD rats were orally administered with GJBRH at doses of 0, 1000, 2000 and 5000 mg/kg/day for 13 weeks and assessed after a 4-week recovery period. Mortality, changes in body weight and food consumption, organ weights, hematology and serum biochemistry were monitored during the experimental period, along with clinical observations, ophthalmological examinations, urinalysis and histopathology. ResultsThere were no significant differences among the eight marker compounds in GJBRH according to storage period. No significant GJBRH-treatment-related toxicological changes were observed in mortality or ophthalmological examinations in either sex. However, soft feces were observed in the male 5000 mg/kg/day group. In addition, there were significant changes in body weight and food consumption in both male and female rats treated with GJBRH at a dose of 5000 mg/kg/day. In the hematological examinations, we found a significant increase in white blood cells, neutrophils and fibrinogen in the 5000 mg/kg/day groups. In the urinalysis, a decrease in the total protein and albumin and an increase in the ovalbumin/globulin ratio were observed in both male and female rats treated with GJBRH at a dose of 5000 mg/kg/day. Histopathological examinations revealed erosion/ulcers and dilated glands in the stomachs of males from the 5000 mg/kg/day group, and squamous cell hyperplasia and epithelial atrophy was observed in the stomachs of both male and female rats treated with GJBRH at a dose of 5000 mg/kg/day. ConclusionThe no-observed-adverse-effect level (NOAEL) was 2000 mg/kg/day for both sexes.

17β-estradiol residue determined in minced meat and it’s Carcinogencity in mice

The main objective of this research to study carcinogenic effects of 17β-estradiol in mice by studying on haematological parameters (Hb, PCV, RBC, WBC and DWBC), mitotic index and histopathological changes of ovary, uterus and mammary gland. The following results which obtained from the current research: The effects of 17β-estradiol for six months on blood picture had no-significant differences on the blood haemoglobin (Hb) (11.55 and 11.69 gm/dl), total number of red blood cells (RBC) counts in the peripheral blood. RBC counts were 7.48 and 6.98 × 106/mm3 for the two groups respectively. Basophiles percent (3.40 and 3.54%) also (8.68 and 8.09%) for Monocytes percent for the two experimental groups respectively. Significant decrease (P˂0.05) in PCV% were noticed between the control and treated group (37.40and 31.28 %) respectively, and Lymphocyte percent (49.00 and 46.03%). Also significant increases (P˂0.05) were observed in the WBC count between the control and the second group (7.05 and 9.43 109/l), and the Neutrophil percent (35.52 and 37.35%) respectively, also significant increases (P˂0.05) in the Eosinophil percent (3.40 and 4.99 %) respectively. The results of carcinogenic effects on cytogenic study showed a significant increase (P˂ 0.05) in mitotic index for mice treated with17β-estradiol in comparison to control group. While the histopathological changes, in ovary: In mice treated with 17β-estradiol revealed immature development of follicles that primordail and primary follicles can be detect while secondary follicle was noted without ova and no griffin follicle can be seen. The histopathological study of uterus: In mice treated with 17β-estradiol showed dilatation of endometrial glands with hyperplasia of epithelial cells lining uterus and there is compact hypercellular stroma. While the histopathological changes, in mammary gland: The mammary gland of treated mice with 17-β estradiol showed pleomorphic hyperchromatic malignant cells in addition somewhere arranged as glandular structure, but the gross appearance of mammary gland adenocarinoma gives enlargement with irregular shape.

Histopathological Investigation of the Stomach of Rats Fed a 60% Genetically Modified Corn Diet

Genetic modification (GM) represents new opportunities for enhanced crop features such as improved insect resistance and herbicide tolerance. The technology allows for cross-species alterations, therefore potentially allowing a vast array of novel traits. Many GM crops have been developed and approved for human and animal consumption. The present study investigated a triple-stacked GM corn variety containing modifications for insect resistance (via cry1Ab and cry3Bb1 genes) and herbicide tolerance (via an EPSPS gene), which was fed to rats for six months. The study investigated the mucosa of the stomach. Alterations to tight junction apposition, gland dilatations with epithelial elongation and dysplasia in the GM-fed rats were observed. These results indicate that GM-corn may have an effect on rat stomach mucosa, which may have health implications.

Notch signaling controls sprouting angiogenesis of endometriotic lesions.

Angiogenesis is essential for the engraftment and growth of endometriotic lesions. In this study, we analyzed whether this process is regulated by Notch signaling. Endometriotic lesions were induced by endometrial tissue transplantation into dorsal skinfold chambers of C57BL/6 mice, which were treated with the γ-secretase inhibitor DAPT or vehicle. Vascularization, morphology, and proliferation of the newly developing lesions were analyzed using intravital fluorescence microscopy, histology, and immunohistochemistry over 14days. Inhibition of Notch signaling by DAPT significantly increased the number of angiogenic sprouts within the endometrial grafts during the first days after transplantation when compared to vehicle-treated controls. This was associated with an accelerated vascularization, as indicated by a higher functional microvessel density of DAPT-treated lesions on day 6. However, inhibition of Notch signaling did not affect the morphology and proliferating activity of the lesions, as previously described for tumors. Both DAPT- and vehicle-treated lesions finally consisted of cyst-like dilated glands, which were surrounded by a well-vascularized stroma and contained comparable numbers of proliferating cell nuclear antigen-positive cells. These findings demonstrate that sprouting angiogenesis in endometriotic lesions is controlled by Notch signaling. However, inhibition of Notch signaling does not have beneficial therapeutic effects on lesion development.

Protein-Losing Hypertrophic Gastropathy, Menetrierʼs Disease, Successfully Managed With Long-Acting Octreotide

Protein-losing gastro-enteropathies are characterized by excessive loss of protein into the gastrointestinal tract. Ménétrier's disease (MD) is a rare disease characterized by extreme foveolar hyperplasia with glandular atrophy in a patient with gross enlargement of gastric folds or ruggae. Little is understood about the pathogenesis of this disease and treatment has mostly consisted of dietary therapy (low-fat, high-protein, medium-chain triglyceride diet.) This case describes a patient with MD successfully managed with Octreotide until he developed intussusception of a large gastric adenoma which required an emergent gastrectomy. A 52 yo AA male was diagnosed with MD after evaluation of a large gastric mass/thickened fold incidentally noted on imaging. An EGD confirmed thickened and large gastric folds. Gastric biopsies demonstrated dilated hyperplastic foveolar glands with stromal edema making the diagnosis of MD (Figure 1, 2). His course was complicated by several hospitalizations for DVTs treated with anticoagulation, severe intra-abdominal hemorrhage due to a complicated LVP, complicated pancreatic fluid collections, volume over load, and severe symptomatic anemia. Labs revealed a hemoglobin of 2.6 g/dL (MCV 58), ferritin 8 ng/ml, iron of < 5 mcg/dL, and Albumin of 0.9 g/dL. For several weeks his Albumin persistently ranged between 0.9 - 1.3 g/dL. Further evaluation revealed an elevated alpha-1-antitrypsin stool clearance >59 ml/day. He was started on octreotide 100mg BID SQ x6 months and subsequently transitioned to long acting Octreotide 20mg IM q4weeks. His albumin increased from 0.9 g/dL to 2.9 g/dL over the following 12-months. His anemia, microcytosis, and iron deficiency normalized. All of his clinical manifestations of hypoalbuminemia resolved and he regained significant muscle mass. Unfortunately, almost 19-months after making the diagnosis of MD he developed a gastric outlet obstruction due to a large fungating gastric adenoma filling and markedly distending the duodenum necessitating an emergent gastrectomy. He recovered well from surgery and continues to do well upon on follow up. Our case demonstrates the potential role of Octreotide as treatment or bridge to surgery for management of patients with protein losing gastropathies as well as as a gastric outlet obstruction from a gastric adenoma, an uncommon complication of this rare disease.Figure: Endoscopic appearance of the stomach showing mucosa edema and polypoid changes of the gastric fundus and body.Figure: Gastrectomy is performed. A, Grossly, there is hypertrophy of the fundal and body mucosa with sparing of the gastric antral mucosa; B-D, histologically, the body and fundal mucosa shows edematous, mildly inflamed lamina propria with hyperplastic.

Giant Fundic Gland Polyps in a Rare Disease

Our patient is a 39-yr-old previously healthy Hispanic female who complains of years of epigastric pain, acutely worsening over the past 2 weeks. She complained of 80lb weight loss, fatigue & intermittent diarrhea over the past 1.5 years. Otherwise review of systems was negative. Medications included omeprazole & ibuprofen prn. Family & social history were unrevealing. On physical examination, vitals were normal with palpable thyroid, mild tenderness over epigastrium with palpation. Lab tests revealed: Hemoglobin 2.1g/dL;hemocrit 8.7%. Multi-chemistry screen was remarkable for Ca 11mg/dL. EGD revealed multiple giant gastric polyps (15-40mm), thickened gastric folds without discrete mass or ulcerations (Figure 1&2). Histology of gastric polyp biopsies showed cystically dilated fundic glands lined by normal gastric epithelium, without evidence of dysplasia, consistent with fundic gland polyps. Colonoscopy was notable for a single diminutive tubular adenoma. Contrasted CT abdomen/pelvis was notable for a mass in the tail of pancreas measuring 1.6cm & portocaval mass measuring 7.8cm. Fasting serum gastrin level was >10000. EUS with FNA of pancreatic & portocaval mass/lymph node was performed with malignant cells of a well differentiated neuroendocrine tumor, low grade. Due to hyperparathyroidism, the patient underwent parathyroidectomy & partial thymectomy that revealed parathyroid adenoma. Our patient met criteria for multiple endocrine neoplasia type 1a with parathyroid tumor, metastatic pancreatic neuroendocrine neoplasm & Zollinger-Ellison syndrome. She was started on high-dose proton pump inhibitor & subcutaneous octreotide injections. Surgical oncology & tumor board consultation yielded decision to continue depot octreotide lifelong given metastatic disease. She underwent evaluation for pituitary tumors including prolactin & MRI of sella turcica, which were negative. Her epigastric pain & anemia improved on PPI and octreotide & will continue surveillance for pituitary tumors & GI tumor progression. Genetic testing revealed a pathogenic mutation in the MEN1 gene (c.1406_1413dupAGCCGTGG), confirming diagnosis of an index case of sporadic MEN1a. Detection of sporadic MEN1a requires a high degree of suspicion & should be considered in cases of epigastric pain, diarrhea with concomitant hyperparathyroidism. Previous association of giant fundic gland polyps & MEN1 has not been reported.Figure: Stomach.Figure: Giant fundic gland polyp.

A Rare Case of Cronkhite-Canada Syndrome

Introduction: Cronkhite-Canada Syndrome (CCS) is a rare non-hereditary polyposis condition with unclear etiology. Estimated incidence is 1 case per million population. Symptoms include diarrhea, anorexia, and weight loss. Dermatologic changes are alopecia, onychodystrophy, and cutaneous hyperpigmentation. Classic endoscopic features include diffuse polyposis which spares the esophagus. Case: 71 yo M with irritable bowel syndrome, diabetes, atrial fibrillation on warfarin presented with abdominal pain, constipation and diarrhea. Gastroscopy and colonoscopy revealed inactive gastritis and two diminutive adenomatous polyps; no microscopic colitis. Over the course of five months diarrhea worsened, he developed dysgeusia and anorexia with a 25 lb weight loss. Exam: hair loss and dystrophic fingernails (Fig 1). Labs: low ferritin, hemoglobin, protein, and albumin. Stool guaic positive. Repeat EGD showed many antral polyps (Fig 2); histology: foveolar hyperplasia and chronic gastritis. Repeat colonoscopy showed many polyps throughout the colon (Fig 3) and terminal ileum; histology: chronic lamina propria inflammation and cystically dilated crypts and glands. Patient diagnosed with CCS. Weight improving on dietary supplements; symptoms are controlled with loperamide and simethicone. He declines steroids.FigureFigureFigureDiscussion: Hallmark features of CCS include diffuse polyps which are usually inflammatory, hyperplastic or juvenile but can be adenomatous. Histology is often non-specific and includes mixed inflammation, expanded lamina propia, cystic dilation of glands and crypts, and villous atrophy. Our patient had no signs of polyposis on recent EGD or nail changes on prior exams. Over 1 year, he developed non-specific symptoms that were unified by diffuse polyposis seen on repeat endoscopy. His disease onset is similar to the relatively acute onset described in the literature. Complications include malabsorption, gastrointestinal bleeding, small bowel obstruction, congestive heart failure, and sepsis. CCS has an increased risk of colon cancer. It is unclear if this relates to pre-existing polyps or is sporadic. Nutrition supplementation is crucial in therapy. Glucocorticoids are the most effective current therapy. Polyp sampling has been advocated for cancer prevention. It is important to be aware of this constellation of symptoms and to refer for endoscopic evaluation. Early diagnosis is key as this rare disease is progressive and confers significant mortality.

Gastric adenocarcinoma at the anastomotic site 50 years after gastrojejunostomy: A case report.

We herein report a rare case of superficially spreading early gastric cancer occurring 50 years after gastrojejunostomy. An 83-year-old woman was diagnosed with gastric cancer after complaining of epigastric discomfort. The patient had undergone gastrojejunostomy with Braun jejunojejunostomy for benign chronic peptic ulcer 50 years prior. Esophagogastroduodenoscopy revealed an irregular nodular lesion on the gastric side of the anastomosis of the gastrojejunostomy. No abnormal lesions were identified by abdominal contrast-enhanced computed tomography. The patient underwent distal gastrectomy with regional lymphadenectomy. The final diagnosis was signet ring cell carcinoma invading the gastric submucosal layer, without lymph node metastasis, located in the area surrounding the original gastrojejunostomy and measuring 9.5×4.5 cm. In addition, dilated cystic glands were found in the submucosal layer, indicating gastritis cystica profunda. Following surgery, the patient remained symptom-free without evidence of recurrence for 46 months. Although it is not clear whether the adenocarcinoma at the stomal site was associated with the superficial spreading-type tumor in the present case, the observations may provide clues as to the pathogenic process of this entity.

Hemorrhagic polyps formed like fundic gland polyps during long-term proton pump inhibitor administration

We report a rare case of hemorrhagic gastric polyps resulting in anemia during long-term proton pump inhibitor (PPI) administration that endoscopically looked like a fundic gland polyp (FGP). A 44-year-old man presented complaining of anemia and tarry stools. Esophagogastroduodenoscopy (EGD) demonstrated multiple white edematous polyps in the corpus and antrum, which were considered to be FGPs. We attempted endoscopic hemostasis but hemorrhaging increased because of hemorrhagic polyps and vulnerable gastric mucosa. Re-bleeding occurred several times. Polyp resection was performed at 24 polyp sites. We also ceased the administration of PPI. Microscopically, polyps showed characteristics of hyperplasia in the foveolar epithelium, extensions of fundic glands, and edema of the stroma. The proliferation of parietal and chief cells was also observed. Immunohistochemically, aquaporin-4 (AQP4) and KCNQ1-positive parietal cells and dilated mucous glands were found from the basal side to the apical side of the mucosa. These findings were compatible with the development of lesions associated with the long-term administration of PPI. EGD revealed an improvement in the vulnerability of gastric mucosa and the development of polyps, with no further gastric polyps observed 1 year after discharge. Bleeding from polyps resembling FGPs is generally rare, with indications that long-term PPI administration may induce such bleeding.

An Uncommon Gastric Submucosal Tumor With Mucosal Erosion

A 54-year-old man with no prior medical history was referred to our hospital for a gastric lesion. An upper endoscopy showed a subepithelial tumor with a central erosion measuring 35 mm in size, located on the posterior wall of the gastric body (Figure A). Biopsy specimens from the depressed and elevated areas showed no neoplastic changes. Endoscopic ultrasonography showed a multicystic heterogeneous component (Figure B). Contrast-enhanced computed tomography showed that some of the cystic components showed contrast (Figure C). T2-weighted magnetic resonance imaging (MRI) also showed multicystic and heterogeneous tissue, and T1-weighted contrast-enhanced MRI showed cystic wall enhancement in the tumor. We successfully performed en bloc resection of the tumor using endoscopic submucosal dissection. The patient was discharged without complication. Histologically, dilated pseudopyloric glands and smooth muscle proliferation were observed in the submucosal layer with inverted and expansive growth (Figure D). Immunohistochemical analysis indicated that those glands were Mucin (MUC)10 and MUC2 negative, and MUC5AC and MUC6 positive. The mucosal layer was defective at the center of the lesion. The horizontal and vertical margins were negative. There was no sign of atypia. The pathologic diagnosis was a gastric hamartomatous inverted polyp (GHIP). GHIPs are rare gastric polyps that account for less than 1% of all gastric tumors.1Iida M. Yao T. Watanabe H. et al.Fundic gland polyposis in patients without familial adenomatosis coli: its incidence and clinical features.Gastroenterology. 1984; 86: 1437-1442Abstract Full Text PDF PubMed Scopus (63) Google Scholar There have been few reports of endoscopic submucosal dissection of GHIP,2Odashima M. Otaka M. Nanjo H. et al.Hamartomatous inverted polyp successfully treated by endoscopic submucosal dissection.Intern Med. 2008; 47: 259-262Crossref PubMed Scopus (22) Google Scholar and this case includes MRI findings. Although GHIP can mimic gastric intestinal stromal tumors,3Mori H. Kobara H. Tsushimi T. et al.Two rare gastric hamartomatous inverted polyp cases suggest the pathogenesis of growth.World J Gastroenterol. 2014; 20: 5918-5923Crossref PubMed Scopus (9) Google Scholar such as in this case, the findings of endoscopic ultrasound, computed tomography, and MRI are relatively specific. The possibility of GHIP should be considered in the differential diagnosis of gastric submucosal tumors because this can help direct therapeutic decisions. GHIP may have a potential risk of malignancy.4Oh S.J. Oh C.A. Kim D.H. et al.Adenocarcinoma derived from gastric hamartomatous polyps.J Korean Surg Soc. 2011; 81: 419-422Crossref PubMed Scopus (9) Google Scholar Although there has been no report of recurrence to our knowledge, annual surveillance has been performed.

Clinical safety and efficacy of vitamin D3 analog ointment for treatment of obstructive meibomian gland dysfunction

BackgroundHyperkeratinization is a major cause of obstructive meibomian gland dysfunction (oMGD) and results in degenerative gland dilation and atrophy without inflammation. Ointment containing 1,25-dihydroxy-22-oxavitamin D3 (maxacalcitol), a noncalcemic analog of the active form of vitamin D3, is applied for the treatment of hyperkeratotic cutaneous conditions such as psoriasis and ichtyosis because it suppresses the proliferation and promotes the differentiation of keratinocytes through interaction with the vitamin D receptor. The aim of the present study was to evaluate the safety and efficacy of maxacalcitol ointment for the treatment of oMGD.MethodsSix eyes of six healthy male subjects (mean age ± SD, 36.4 ± 10.8 years) and 12 eyes of eight oMGD patients (five men and three women; mean age ± SD, 55.6 ± 13.2 years) were enrolled in the study. Maxacalcitol ointment was applied to the upper and lower lid margins twice a day for 8 weeks. Subjective symptoms, lid margin abnormalities, tear film breakup time (BUT), ocular surface staining, meibum grade, Schirmer test value, and meibomian gland area were evaluated in the oMGD patients before, during, and after the treatment period.ResultsSevere adverse effects of ointment application were not observed in the healthy subjects or oMGD patients. The clinical scores for plugging of meibomian gland orifices and lid margin vascularity as well as BUT, meibum grade, and meibomian gland area were significantly improved in oMGD patients after the 8-week treatment period compared with pretreatment values (P values of <0.001, 0.020, 0.030, 0.020, and 0.017, respectively).ConclusionsTopical eyelid application of an analog of the active form of vitamin D3 was found to be safe as well as to improve the condition of patients with oMGD. Such ointment thus warrants further evaluation as a potential new treatment option for this condition.Trial registrationThis study was registered with the UMIN database (ID: UMIN000016230) on 16 January 2015.

Fundic Gland Polyps in the Pediatric Population: Clinical and Histopathologic Studies.

We retrospectively studied the clinical and histologic features of pediatric fundic gland polyps (FGPs) in 16 patients. FGPs had an endoscopic prevalence of 0.25% in 8527 pediatric gastric biopsies. Five patients had familial adenomatous polyposis (FAP). The median age of onset was 17.7 years in FAP and 17.3 years in sporadic patients. All syndromic patients were asymptomatic and FGPs were identified during surveillance for existing or concurrent colon polyps. They did not take antacids. In comparison, all 11 sporadic FGPs were identified during evaluation of symptomatic patients who had taken antacids (median duration 21 months). Syndromic FGPs can be multiple at single endoscopy and were more likely to recur, while sporadic FGPs were often single. None of the sporadic patients had recurrence of FGPs or a subsequent diagnosis of FAP during a median follow-up of 20.5 months. The dilated fundic glands were lined by parietal and chief cells only in a majority (22/41, 53.7%) of syndromic FGPs, while additional tall mucinous lining cells were found in all sporadic FGPs. Syndromic FGPs did not have parietal cell hypertrophy in the background oxyntic mucosa. Nuclear immunopositivity for beta-catenin was essentially absent in all the FGPs. In conclusion, FGPs were rare in pediatric patients. In syndromic patients, FGPs are asymptomatic and did not precede colon polyps. Prolonged antacid intake seems to be associated with development of sporadic FGPs. Cellular components of dilated fundic glands and background parietal cell hypertrophy can be useful features to eliminate concern for syndromic polyposis.

Massive gastric juvenile-type polyposis: a clinicopathological analysis of 22 cases.

Massive gastric polyposis is a rare entity that is often associated with juvenile polyposis syndrome (JPS). The aim of this study was to evaluate the clinicopathological features of 22 patients with abundant gastric juvenile-type or hyperplastic-like polyps. The study included 12 males and 10 females with a median age of 48 years (range: 13-79 years). Fourteen (64%) patients carried a diagnosis of JPS, and three had prior gastrointestinal adenocarcinomas. Patients without known JPS presented at an older median age (60 years versus 40 years; P = 0.0068). Clinical symptoms included nausea, vomiting, and abdominal pain; 23% of patients were asymptomatic. Eighteen cases showed complete or near-complete carpeting of the gastric mucosa by innumerable polyps, ranging from a few millimetres to ~100 mm. Most polyps formed long, bulbous projections and had characteristic histological features, including a smooth outer contour, prominent stromal oedema, and widely spaced, often cystically dilated glands lined by foveolar epithelium; some polyps had less stroma and more hyperplastic foveolar epithelium. All had normal underlying or adjacent mucosa. Four (18%) cases harboured adenocarcinoma, and seven (32%) others showed dysplasia. SMAD4 immunohistochemical staining showed patchy loss in polyps from 19 of 20 cases tested. Five of six (84%) patients tested had a germline SMAD4 mutation. Massive gastric juvenile-type polyposis can occur in patients with and without known JPS, and may mimic different conditions, such as other polyposis syndromes and Ménétrier disease. Pathologists play an important role in disease classification, as some patients lack a family or personal history of JPS, have few if any colonic polyps, and may not harbour diagnostic germline mutations.

Gastric mucosal cracked and cobblestone-like changes resulting from proton pump inhibitor use.

Use of proton pump inhibitors (PPI) is histologically associated with oxyntic gland dilatations. Two interesting mucosal changes are often detected endoscopically in patients who use PPI: gastric cracked mucosa (GCM) and gastric cobblestone-like mucosa (GCSM). The aim of the present study was to clarify the relationship between PPI use and these mucosal changes. This was a single-center observational study. All successive subjects who underwent a routine esophagogastroduodenoscopy (EGD) between August and November 2014 in Hokkaido University Hospital were enrolled. Endoscopists carried out the assessment blinded to the use of PPI and checked for GCSM and GCM using original diagnostic criteria for GCM and GCSM. Subjects were divided into two groups: those who used PPI (PPI group) and those who did not (control group). Endoscopic findings and backgrounds were compared between the two groups. A total of 538 patients were analyzed (control group: 374 patients, men/women: 204/170, median age: 65.2 years; PPI group: 164 patients, men/women: 89/75, median age: 67.1 years). GCM was detected in 54 (10.0%) subjects, and GCSM was detected in 18 (3.3%) subjects. There was a significant difference in the prevalence rate of GCM between the control group (14/374, 3.7%) and the PPI group (40/164, 24.4%) (P < 0.01). GCSM was significantly more prevalent in the PPI group (15/164, 9.1%) than in the control group (3/374, 0.8%) (P < 0.01). Novel GCM and GCSM endoscopic findings in the corpus area seem to be strongly associated with PPI use.