Intramural Lesions Research Articles

Dysregulation of sympathoadrenal system activity in patients with microvascular angina

Abstract Introduction Recent studies have highlighted that a significant proportion of patients (up to 47%) undergoing coronary angiography due to clinical indications do not exhibit significant stenosis in epicardial vessels. Among these patients, up to 50% may suffer from microvascular angina (MVA). Despite the absence of intramural coronary artery lesions typically associated with atherosclerosis, the occurrence of transient myocardial ischemia and cardiac pain syndrome raises interest due to the incomplete understanding of their underlying mechanisms. Objective This study aims to comprehensively investigate sympathoadrenal system activity in patients with microvascular angina. Materials and Methods A total of 40 patients diagnosed with MVA, aged 35-76 years, including 11 (27.5%) men and 29 (72.5%) women, were enrolled, along with 20 healthy individuals. Assessment of sympathoadrenal system (SAS) activity involved determining daily urinary excretion levels of free and conjugated catecholamine fractions (CA) using solid-phase enzyme immunoassay: adrenaline (A), noradrenaline (NA), dopamine (DA), and DOFA. Additionally, catecholamine deamination enzyme activity—monoamine oxidase (MAO)—was determined using solid-phase EIA. Results Patients with MVA exhibited a significant increase in the excretion of all CA fractions. Specifically, adrenaline (A) excretion increased by 56.7%, surpassing the control by 1.7 times (p<0.001). Noradrenaline (NA) levels were elevated by 59.5% in MVA patients, which was 1.6 times higher than the control group (p<0.001). Dopamine (DA) levels in MVA patients increased by 31.0%, surpassing control values by 1.36 times (p<0.001). Moderate elevation in DOFA levels by 19.7% was observed, which was 1.23 times higher than the control (p<0.01). Ratios of CA sulfocatecholamine formation processes indicated pronounced deviations from normal. Gender differences revealed marked changes in sympathoadrenal activity, particularly in women (p<0.001). Studies of MAO activity on the first day identified a moderate decrease in its activity in MVA patients—0.03±0.002 units/ext. (p<0.01), while healthy individuals exhibited an activity level of 0.07±0.001 units/ext. Conclusion The findings underscore the crucial pathogenetic role of SAS in the development of MVA. The study demonstrates that the severity of ischemia correlates with disruptions in SAS components. Notably, these disruptions are pronounced in MVA, indicating an overload of the sympathoadrenal system—a critical component of organismal homeostasis. Under conditions of SAS overload, the pivotal enzyme in biogenic amine oxidation, MAO, undergoes significant transformation, leading to reduced activity towards monoamines. These findings were consistent with our clinical investigation.

487. A RARE CASE OF BRONCHOGENIC CYST ESOPHAGUS

Abstract Introduction Bronchogenic cyst is a relatively rare congenital malformation that develops from abnormal budding of the ventral foregut during the early stage of gestation. Histologically, the cyst wall is covered by respiratory-type ciliated epithelium that may include cartilage and bronchial glands. Case report We present a 20 yrs male with chest discomfort during swallowing for 6 months. Evaluated with Upper GI scopy showed smooth mucosal elevation 30-35 cm from incisors. CECT Chest Showed features of Intramural cystic lesion of size 7x7cm.Patient was evaluated and taken up for surgery. Robotic Thoracoscopic cyst excison was done. Intraoperatively 7x7cm cystic lesion in lower esophagus infra carinally. Cyst has no communication with mucosa. Post operatively patient recovered well, Drin removed on 3 rd Post operative day and Patient was discharged on 4 th day. Histopathology showed the cyst wall is covered by respiratory-type ciliated epithelium that may include cartilage and bronchial glands https://1drv.ms/v/s!AklfEcoVwf9chCmLN-FSXBA2yV3B

Management of subepithelial esophageal tumors

Abstract Subepithelial esophageal tumors (SET) are normally benign intramural esophageal lesions of mesenchymal origin. Although rare, the incidence of SET has increased in recent decades due to the more widespread use of endoscopy and diagnostic imaging. The current review aims to provide an overview of the histopathologic spectrum and the most frequent entities including leiomyoma and gastrointestinal stromal tumor (GIST), diagnostic workup, and multidisciplinary treatment options. Staging for SET should include endoscopy, endoscopic ultrasonography (EUS), and tissue sampling. Current consensus guidelines recommend that SET suggestive of gastrointestinal stromal tumor (GIST) larger than 20 mm or lesions with high-risk stigmata should undergo tissue sampling. Most SET have an excellent long-term outcome, but malignancy may be present in certain subtypes. Asymptomatic SET without high-risk stigmata discovered incidentally usually do not require specific treatment. However, depending on the size and location of the lesion symptoms may occur. Therapeutic interventions range from endoscopic interventional resections to major surgical procedures. Enucleation via minimally invasive or robotic-assisted access remains the standard of care for most SET sub-entities.

990 A Rare Case of Adenomyoma in Gastric Pylorus of a Young Adult Female: A Case Report

Abstract Introduction Gastric adenomyoma is a rare benign tumour which occurs 85% in antrum and 15% in pylorus. Although adenomyomas are benign, diagnosis is difficult as they are commonly found alongside with adenocarcinomas. Case report A 20-year-old previously healthy female presented with epigastric pain, gastric outflow obstruction features and weight loss for 3 months. Initial USS was followed by a CECT which, showed intramural mass lesion with necrotic centre arising from the inferior wall of the pre pyloric area of the stomach with acute inflammatory changes of the adjacent omental fat, giving differential diagnosis of GIST or gastrinoma at pyloric region. Subsequent upper GI endoscopy revealed a protruding pyloric mass without mucosal lesions. Unfortunately, the unavailability of EUS and biopsy posed a diagnostic hurdle. Intraoperatively, a mass intricately adhered to the transverse colon and omentum was discovered, leading to a surgical intervention involving distal gastrectomy, gastrojejunostomy, and jejunojejunostomy. Unexpectedly, histological analysis unveiled adenomyoma at the prepyloric area, characterized by Brunner’s glands, dilated glands, and heterotrophic small intestinal tissue. Discussion This rare manifestation of adenomyoma in the gastric pylorus, particularly in a young adult, highlights the challenges in accurate preoperative diagnosis. The favourable postoperative outcome prompts reflection on the potential role of advanced diagnostic tools, emphasizing the significance of EUS and biopsy in steering clear of extensive surgeries. Conclusions This case report underscores the crucial role of personalized diagnostic methods, especially in cases like ours where a rare adenomyoma mimicking other tumours.

Uterine Tumor Resembling Ovarian Sex-Cord Tumor (UTROSCT): A Rare Polyphenotypic Neoplasm.

Uterine tumor resembling ovarian sex-cord tumor (UTROSCT) is a rare form of uterine mesenchymal neoplasm. Although UTROSCT generally exhibits benign behavior with a favorable prognosis, this neoplasm is nevertheless classified as being of uncertain malignant potential, given its low rate of recurrence and the fact that it rarely produces metastases (e.g., in the lymph nodes, epiploic appendix, omentum, small bowel, subcutaneous tissue, lungs). Its histogenesis is also uncertain. Typically, UTROSCT occurs in peri-menopausal or menopausal women, but it can sometimes be observed in young women. Usually, this neoplasm can be found in the uterine corpus as a nodular intramural lesion, while it is less frequently submucosal, subserosal, or polypoid/intracavitary. UTROSCT can cause abnormal bleeding, pelvic pain, enlarged uterus, and mass sensation, but sometimes it is found purely by chance. This neoplasm can be considered polyphenotypic on morphological, immunohistochemical, and genetic analyses. Generally, upon microscopic examination, UTROSCT shows a predominant pattern of the cords, nests, and trabeculae typical of sex-cord tumors of the ovary, while immunohistochemically it is characterized by a coexpression of epithelial, smooth muscle, and sex-cord markers. The aim of this review is to report clinical and pathological data and genetic alterations to establish their impact on the prognosis and management of patients affected by this rare entity.

Clinical and imaging differences between Stanford Type B intramural hematoma-like lesions and classic aortic dissection

BackgroundIntramural hematoma (IMH) and Aortic dissection (AD) have overlapping features. The aim of this study was to explore the differences between them by comparing the clinical manifestations and imaging features of patients with acute Stanford type B IMH-like lesions and acute Stanford type B AD (ATBAD).MethodsThis study retrospectively analysed the clinical and computed tomography angiography (CTA) imaging data of 42 IMH-like lesions patients with ulcer-like projection (ULP) and 38 ATBAD patients, and compared their clinical and imaging features.Results(1) The IMH-like lesions patients were older than the ATBAD patients (64.2 ± 11.5 vs. 50.9 ± 12.2 years, P < 0.001). The D-dimer level in the IMH-like lesions group was significantly higher than that in the ATBAD group (11.2 ± 3.6 vs. 9.2 ± 4.5 mg/L, P < 0.05). The incidence rate of back pain was significantly higher in the ATBAD group than in the IMH-like lesions group (71.1% vs. 26.2%, P < 0.05). (2) The ULPs of IMH-like lesions and the intimal tears of ATBAD were concentrated in zone 4 of the descending thoracic aorta. The ULPs of IMH-like lesions and the intimal tears of ATBAD were mainly in the upper quadrant outside the lumen (64.3% vs. 65.8%, P > 0.05). (3) The maximum diameter of the ULPs in IMH-like lesions was smaller than that of the intimal tears in ATBAD (7.4 ± 3.4 vs. 10.8 ± 6.8 mm, P = 0.005). The lumen compression ratio in the ULPs plane and the maximum compression ratio of the aortic lumen in the IMH-like lesions group were smaller than that in the ADBAD group (P < 0.05). Fewer aortic segments were involved in IMH-like lesions patients than in ATBAD patients (5.6 ± 2.2 vs. 7.1 ± 1.9 segments, P < 0.005). The IMH-like lesions group had less branch involvement than that of the ATBAD group (P < 0.001).ConclusionThe degree of intimal tears, lumen compression ratio, extent of lesion involvement, and impact on branch arteries in ATBAD are more severe than that of IMH-like lesions. But for the ULPs of IMH-like lesions and intimal tears of ATBAD, they have astonishing similarities in the location of the partition and the lumen quadrant, we have reason to believe that intimal tear is the initial factor in the pathogenesis of this kind of disease, and their clinical and imaging manifestations overlap, but the severity is different. Concerning similarities between these two conditions, these two may be a spectrum of one disease.

EUS-Guided Diagnosis of Gastric Subepithelial Lesions, What Is New?

Gastric subepithelial lesions (SELs) are intramural lesions that arise underneath the gastric mucosa. SELs can be benign, but can also be malignant or have malignant potential. Therefore, correct diagnosis is crucial. Endosonography has been established as the diagnostic gold standard. Although the identification of some of these lesions can be carried out immediately, solely based on their echo characteristics, for certain lesions histological examination is necessary. Sometimes histology can be inconclusive, especially for smaller lesions. Therefore, new methods have been developed in recent years to assist decision making, such as contrast enhanced endosonography, EUS elastography, and artificial intelligence systems. In this narrative review we provide a complete overview of the gastric SELs and summarize the new data of the last ten years concerning the diagnostic advances of endosonography on this topic.

Multiple Esophageal Leiomyomas: Case Report

Esophageal leiomyoma is uncommon. It is the most common benign tumor of the esophagus accounting for 0.4% of esophageal neoplasms and approximately two-thirds of benign esophageal tumors. About 90% of them are reported to be solitary and intramural lesions, and multiple or diffuse lesions seem to be very rare. We report the observation of a 75 years old male patient who was evaluated for chronic epigastric pain, Physical examination findings were typically normal, the patient underwent upper GI endoscopy. In esophagus, many submucosal tumor covered with intact mucosa, varying between 5mm and 20mm in size and located in the middle and lower part of oesophagus were noted. The radial endoscopic ultrasonography showed multiple (&gt;10 masses), homogenous hypoechoic masses with clear margins, originated from the submucosa layer with normal surrounding structures, located in the middle and lower part of the oesophagus, and their size was &lt; 2 cm, these lesions are followed periodically as they have a slow growth rate and negligible risk of malignant transformation. Multiple esophageal leiomyomas seems to be very rare, EUS is a valuable technique for the diagnosis of the disease and for making treatment decisions.

Role of MR enterography versus ileo-colonoscopy in the assessment of inflammatory bowel diseases

BackgroundInflammatory bowel disease (IBD) is widespread and rapidly rising in developing countries. It remains a significant issue in Western culture with a prevalence of more than 0.3%. Symptom control has been the only focus of treatment before the discovery that many individuals with IBD continue to have disease activity even in the absence of clinical symptoms. Therefore, treatment goals now include establishing clinical remission, steroid-free remission, and mucosal healing, which may eventually be complemented by transmural healing in cross-sectional imaging modalities. Magnetic resonance enterography (MRE), computed tomography enterography, and small-bowel ultrasound are now reliable methods for staging intramural lesions and extramural consequences in CD and for determining disease activity and severity. Recently literature suggests the incorporation of (MRE) for periodic reevaluation of IBD patients, as it offers small-bowel, colonic, and extra-enteric assessment as well as monitors the response to the anti-inflammatory therapy. The purpose of the current study was to compare MRE with ileo-colonoscopy findings in the diagnosis of IBD features, specifically Crohn's disease, and ulcerative colitis, as well as in the detection of disease exacerbation (Activity).ResultsThis study used MRE and ileo-colonoscopy to assess chronic inflammatory bowel disease patients; the patient population (n = 30) was made up of (14/30, 46.7%) females and (16/30, 53.3%) males, with a mean age of 32 ± SD 13 years. MRE alone detected lymphadenopathy in 73.3% of patients, and mural thickening with a mean of 4.1 ± SD 5.1 mm. It has detected mucosal enhancement with 80% sensitivity and 60% specificity. However, it was unable to detect mucosal erosions or ulceration.ConclusionsMRE is sensitive, inexpensive, noninvasive, and radiation-free for inflammatory bowel disease detection, with 86.7% diagnostic accuracy for affected areas. Unlike ileo-colonoscopy, it could examine the entire small intestine, precisely measure the affected loop, and detect activity signs such as mural thickening and lymphadenopathy. Only ileo-colonoscopy could detect mucosal degradation and superficial ulcers. IBD treatment protocols should incorporate MRE for small-bowel, colonic, and extra-enteric assessment, monitoring of disease activity, and anti-inflammatory therapy response.

Feasibility of simultaneous multichannel magnetocardiographic mapping, multiple monophasic action potential recording and laser photocoagulation of isolated and perfused rabbit ventricular myocardium

Abstract Background Multichannel magnetocardiographic mapping (MCG) has been validated as an accurate non-invasive method for 3D localization of arrhythmogenic substrates suitable for ablation treatment and of intracardiac electrophysiology catheters (1,2). High resolution (HR) MCG-guided multiple simultaneous monophasic action potential (multi-MAP) recording and pacing with a single patented amagnetic catheter (AC) detects local arrhythmogenic mechanisms (3). Laser photocoagulation (LP) providing more controlled and homogeneous myocardial lesions (4), may be an alternative to radiofrequency (RF) ablation, without unwanted electromagnetic noise effect during real-time MCG. Purpose This study aimed to experimentally test the feasibility of simultaneous multi-MAP recording and LP guided by real-time MCG. Methods An unshielded 36 channels SQUID system (sensitivity of 30 fT/Hz1/2, at 1 Hz) (CMI, USA) was used to study Langendorff-perfused isolated rabbit heart with MCG (Figure 1A). Four epicardial MAPs were simultaneously recorded (inter MAP distance: 1 mm) with a single multi-MAP AC (bandpass: DC-500 Hz; sampling frequency: 2 kHz) (GE-Prucka Cardiolab). LP was performed with a NdYAG laser (Dornier Medilas 5100) and a catheter system for safe myocardium LP (5). The study was carried out according to NIH guidelines for animal care and use. Results MCG imaging of rabbit ventricular magnetic field distribution and inverse source localization with the magnetic dipole model are shown in Figure 1B. The difference in morphology of local HR ventricular multi-MAP signals was compatible with myocardial anisotropy (Figure 1C). With appropriate cooling of the optic fiber-tissue interface, no epicardial damage was induced by LP, whereas deeper well defined intramural myocardial lesions were appreciable, of different size as a function of the energy delivered (Figure 1D). Multi-MAP recording was not significantly disturbed by LP. Keeping the Medilas unit at least 5 meters away from the MCG sensors, no electromagnetic artifacts were observed during MCG. Conclusion MCG, single catheter multi-MAP recording and well-defined LP lesions of ventricular myocardium were simultaneously feasible on Langendorff-perfused isolated rabbit heart, without major electromagnetic interferences, in an unshielded catheterization laboratory. With appropriate technological developments, safe MCG-guided single-catheter laser ablation of focal arrhythmogenic substrates is foreseen as a possible minimally invasive alternative to current interventional approaches. Funding Acknowledgement Type of funding sources: None.

S3697 A Case of a Pyloric Gland Adenoma Presenting as an Intramural Mass

Introduction: Pyloric gland adenomas (PGA) are a subset of gastric adenomas with malignant potential. They are often characterized on endoscopy as an intraluminal polypoid, dome-shaped, ulcerating, or fungating mass. Due to their risk of carcinogenesis, it is important to recognize and resect lesions that are suspicious for PGAs for further pathological examination to confirm the diagnosis. Although PGAs are characterized as mucosal or submucosal lesions, this case reviews an atypical presentation of a PGA that presents intramurally in the stomach without the common features typically visualized on direct endoscopy. Case Description/Methods: A 65-year-old female with history of GERD presented with a one-year history of globus sensation described as irritation in her throat without associated weight loss, dysphagia, or odynophagia. Symptoms were refractory to proton pump inhibitors and H2 blockers. Upon initial endoscopic evaluation, a friable 3-centimeter region of localized nodular mucosa without ulceration was found on the greater curvature of the stomach and biopsied (Figure 1A). Initial pathology report noted epithelial proliferation within gastric mucosa, but malignancy was not excluded. Follow-up CT scan showed a 1.8 × 1.3 × 1.1 centimeter intramural lesion within the greater curvature at the level of the gastric fundus (Figure 1B). Upon repeat endoscopy, re-biopsy of the lesion with snare resection for more robust tissue sampling confirmed an intramucosal adenocarcinoma arising in a pyloric gland adenoma. The patient subsequently underwent a subtotal gastrectomy with Roux-en-Y gastrojejunostomy and has begun receiving adjuvant chemotherapy with folinic acid, fluorouracil and oxaliplatin (FOLFOX). Discussion: This case demonstrates the variability in presentation of PGAs while also highlighting the carcinogenic potential to evolve into an adenocarcinoma. Unlike typical PGAs that are mucosal or submucosal, this case describes an intramural PGA, which to our knowledge, has yet to be reported in the literature. Although their incidence is rare, PGAs should be considered on the differential for atypical lesions visualized on endoscopy due to their malignant potential.Figure 1.: Friable nodular ulceration on greater curvature of stomach (A), Intramural lesion within greater curvature at level of gastric fundus on CT scan (B).

S2400 Granular Cell Tumor: A Rare Disease of Esophagus

Introduction: Granular cell tumors (GCTs) are rare, often benign tumors of neurogenic origin. GCTs are usually found incidentally but can present with dysphagia in symptomatic patients. They are diagnosed via biopsy and histology following an esophagogastroduodenoscopy( EGD). We present a case of a 46-year-old female who presented with dysphagia, GERD, and weight loss diagnosed with esophageal granular cell tumor following an EGD. Case Description/Methods: A 46 years old female with a past medical history of H. pylori gastritis presents with complaints of dysphagia for 3 months and GERD associated with weight loss. EGD reviewed a single 4 mm nodule found in the lower third of the esophagus with the appearance of a lipoma (Figure). Biopsy of esophagus nodule resulted in esophageal squamous epithelium with focal granular cell tumor; Immunohistochemistry tumor cells are positive for S100, CD56, CD68, negative for calretinin and AE1/3 supporting rare esophageal granular cell tumor. EUS demonstrated a 4.7 mm x 2.6 mm intramural (subepithelial) lesion appeared to originate from within the superficial mucosa (Layer 1), Patient underwent repeat EGD with en-bloc cap and band-assisted endoscopic mucosal resection (EMR) followed by 3 hemoclips placed for hemostasis. The patient was discharged home on a proton pump inhibitor. The patient reports clinical improvement on follow-up after 4 weeks. Discussion: GCTs are thought to originate from Schwann cells; the prevalence of GCTs is challenging to determine as there have been roughly 300 documented cases of GCTs discussed in the literature. Conversely, patients with larger diameter lesions typically present with indolent dysphagia and other less common symptoms such as gastro-esophageal reflux disease, dyspepsia, chest pain, cough, or nausea. GCTs on EGD appear sessile, yellow-white in color, and firm, with a negative pillow sign. After performing EGD, an endoscopic ultrasound (EUS) is diagnostically utilized to ascertain tumor invasion and provide a biopsy through fine needle aspiration (FNA). Histopathological diagnosis, including immunohistological staining, is essential for confirmation of GCT. Immunohistological staining is positive for S-100, PAS (Periodic Acid Schiff), neuron-specific enolase, nestin, and vimentin. Patients whose neoplasms are less than 1 cm in diameter are treated conservatively with endoscopic follow-up, with tumors greater than 1 cm in diameter, or having clinical symptoms that need endoscopic or surgical resection.Figure 1.: A: EUS showing 4.7 mm x 2.6 mm hypoechoic intramural (subepithelial) lesion was found in the lower third of the esophagus. It appeared to originate from within the superficial mucosa (Layer 1). A tissue diagnosis was obtained prior to this exam. B: EGD significant for sessile, yellow white in color, and firm mass followed by EMR. C: Histopathology with H&E showing clusters of polygonal cells with granular eosinophilic cytoplasm (top) and S100 stain (below).

S2436 A Rare Case of a Large Esophageal Gastrointestinal Stromal Tumor

Introduction: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms, accounting for approximately 1 to 2 percent of primary gastrointestinal (GI) cancers. Presenting symptoms include abdominal pain, nausea, vomiting, early satiety, bleeding, and dysphagia, but vary depending on primary tumor location. Most tumors are discovered incidentally with the majority found in the stomach (40 to 60 percent) followed by small bowel (25-30 percent), colon and rectum (5-15 percent). We present a case of an elderly patient diagnosed with esophageal GIST after he was found to have an incidental esophageal mass on imaging. Case Description/Methods: 80-year-old male with PMH of HTN, HLD, DM2, CKD Stage III, COPD, former tobacco user was referred for an upper endoscopy for evaluation of an incidental finding on CT scan. CT demonstrated a mass arising from the distal esophagus, measuring 6.5 x 7.5 cm. Patient denied any dysphagia, abdominal pain, nausea, vomiting, weight loss, hematemesis, or melena. Endoscopy showed submucosal mass in the distal esophagus (Figure). Biopsy was inconclusive and subsequent EUS-guided fine needle biopsy was performed. Upper endoscopic ultrasound (EUS) showed an intramural lesion in the distal esophagus arising from the muscularis propria. Pathology results confirmed GIST, positive for CD117 and DOG-1. Further testing revealed a mutation in the KIT gene exon 11. Patient is currently undergoing neoadjuvant therapy with imatinib mesylate with anticipated surgical resection. Discussion: This is a rare case of a large esophageal GIST. Most mesenchymal esophageal tumors are leiomyomas, and GIST only accounts for 0.7% of them. EUS with fine need aspiration biopsy is the most accurate method for diagnosis and definite diagnosis is made histologically. Majority of GISTs, expresses the CD117 antigen, a KIT receptor tyrosine kinase. Another commonly found mutation is the platelet derived growth factor (PDGFRA) tyrosine kinase gene. Tumor size and mitotic rate are used for prognostication, with increased malignancy risk seen in tumor size > 3 cm with irregular margins. Tumor location is also a key factor in risk stratification; non gastric primary location has higher rates of metastases. Liver and peritoneum are the most common sites of metastatic GISTs. Treatment focuses on surgical resection and neoadjuvant therapy with imatinib. Given significant implication for its management, esophageal GIST should be considered in differential diagnosis and distinguished from more common esophageal leiomyomas.Figure 1.: Submucosal mass in distal esophagus.

A Fortunate Twist

Question: A 37-year-old Chinese woman was presented with a 1-day history of colicky central abdominal pain associated with 5 episodes of vomiting and diarrhea. It was the third day of her menstrual cycle. On examination, the abdomen had generalized distension without tenderness. There were no significant constitutional symptoms or family history of bowel malignancy, or personal history of inflammatory bowel disease. Her past medical and surgical history reveals a previous large left endometriotic cyst of 14 cm in 2010 for which she underwent a laparoscopic cystectomy, as well as primary subfertility for which she was undergoing her third cycle of in vitro fertilization (IVF) at the time of presentation. Initial blood investigations revealed elevated white cell count of 17,500/mm3, a normal hemoglobin of 15.4 g/dL, and borderline raised C-reactive protein of 36.2 mg/dL. Computed tomography scan of the abdomen and pelvis revealed small bowel obstruction with transition points at the terminal/distal ileum where enhancing intramural lesions has resulted in luminal narrowing and bulging at the ileocaecal junction (Figure A). There were also several small lesions indeterminate for peritoneal nodules. The patient was offered diagnostic laparoscopy with potential for laparotomy and bowel resection to relieve the obstruction. What do you think the final diagnosis was? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. During diagnostic laparoscopy, hemorrhagic ascites was noted, which was sent for cytology. A decision was made to convert to a laparotomy in view of limited workspace due to the grossly dilated bowel loops. Intraoperative findings were significant for 2 lesions – 1 in the terminal ileum and the other in the ileocaecal valve (Figures B and C), causing small bowel obstruction. Three peritoneal nodules were noted, biopsied, and sent for histology (Figure D). A limited right hemicolectomy was performed to remove the lesions causing obstruction. The patient made a full recovery 6 days after surgery and was discharged well. Histology reports for both the peritoneal nodules and the right hemicolectomy specimen were consistent with endometriosis. Endometriosis is a common gynecologic condition where endometrium, which usually lines the uterine cavity, is found in other areas of the body. When endometrial tissue starts to grow in the ovaries or fallopian tubes, this may result in blockages in the fallopian tubes, which may form scar tissue and reduce the fertility of a woman. Such patients can be offered IVF. However, there is a potential risk of worsening endometriosis due to ovarian hyperstimulation syndrome.1Seyer-Hansen M. Egekvist A. Forman A. et al.Risk of bowel obstruction during IVF treatment of patients with deep infiltrating endometriosis.Acta Obstet Gynecol Scand. 2018; 97: 47-52Crossref PubMed Scopus (17) Google Scholar Although uncommon, gastrointestinal tract involvement by endometriosis can occur with 90% of lesions localized to the terminal ileum, sigmoid colon, or rectum. However, acute bowel obstruction as a complication of bowel endometriosis is rare and only accounts for <1% of most presentations.2De Ceglie A. Bilardi C. Blanchi S. et al.Acute small bowel obstruction caused by endometriosis: a case report and review of the literature.World J Gastroenterol. 2008; 14: 3430-3434Crossref PubMed Scopus (79) Google Scholar In this case vignette, the initial top differential was that of a neoplastic lesion with peritoneal metastases. In retrospect, endometriosis involving the gastrointestinal tract should have been considered as a differential diagnosis. The patient had a known history of endometriosis with history of colicky abdominal pain during menstruation that could well be related to intermittent subacute bowel obstruction caused by bowel endometriosis. The patient was also undergoing IVF, which could lead to ovarian hyperstimulation syndrome and increase symptoms related to endometriosis. Other rare manifestations of symptomatic endometriosis during IVF treatment include that of thoracic endometriosis as well as urogenital endometriosis, which can cause ureteral obstruction.3Ponticelli C. Graziani G. Montanari E. Ureteral endometriosis: a rare and underdiagnosed cause of kidney dysfunction.Nephron Clin Practice. 2010; 114: c89-c94Crossref PubMed Scopus (0) Google Scholar

Pacing electrodes to ablate, not to pace: what settings to use to create lesions even deep in the septum

Abstract Funding Acknowledgements Type of funding sources: None. Background Intramural septal ventricular arrhythmia remains challenging, requiring emergent technologies and experimental approaches. Although conduction system pacing (CSP) has allowed us to reach deep in the septum, ablation though pacing electrodes has not been examined yet. Purpose To evaluate lesion creation by radiofrequency ablation (RFA) through pacing electrodes. Methods A custom ex vivo swine model in a saline bath with an indifferent electrode was used to apply RFA with an 8 mm non-irrigated catheter (SJM, MN, USA) on the proximal end of pacing (CapSureFix 5086) or CSP-electrodes (SelectSecure 3830, Medtronic, MN, USA), screwed in perpendicularly to the slab. A generator (Ampere, SJM, MN, USA) applied RFA at varying settings (1-10 W, 1-20 sec). Lesion depth (D), width (W) and volume (V=3,14*W2*D/4) were assessed and analyzed (SPSS 23). Results A total of 80 lesions were used for analysis. Median RFA with 3 W over 6 sec resulted in an impedance drop from 200 to 140 Ω and a lesion of 2x3 mm or 9.4 mm3 (Figure 1). Higher energy settings caused impedance rise with abort (n=3, 4%) or charring (n=3, 4%). Compared to conventional electrodes, lesions with CSP-electrodes had similar volume (9.3±7 vs. 10.8±9 mm3, p=0.45) and width (2±0.8 vs. 2±0.7, p=0.58), but more depth (2.6±0.5 vs. 3±0.6, p=0.0.01). Regression analysis showed final-impedance (FI), power and duration (WS=W*Sec) as independent predictors of lesion volume (V=4.7WS-4.1WS2+4.5FI-4, p&amp;lt;0.001). Conclusions Effective ablation through pacing electrodes is possible, but lesion size is limited and low-power settings are necessary. Using CSP-electrodes for effective intramural lesions is possibly a new tool for septal arrhythmias. Further in vivo studies are warranted and bailout use should be considered.

A case of ectopic pancreas of the stomach accompanied by intraductal papillary mucinous neoplasm with GNAS mutation

BackgroundEctopic pancreas is basically a benign disease and is not always necessary to be removed. However, all types of neoplasms occurring in the normal pancreas such as ductal adenocarcinomas and intraductal papillary mucinous neoplasms (IPMNs) may develop even within ectopic pancreas. We recently encountered an extremely rare case of ectopic pancreas in the gastric antrum associated with IPMN possessing a GNAS mutation.Case presentationA 71-year-old Japanese woman complained of epigastric pain. Computed tomography and upper gastrointestinal endoscopy showed an intramural cystic mass in the antrum of the stomach. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy did not give a definitive diagnosis, and the patient underwent resection of the lesion. Histology of the resected specimen showed that the gastric intramural lesion was ectopic pancreas. Moreover, the lesion contained dilated duct components with tubulo-villous epithelial proliferation consistent with pancreatic IPMN. Since the covering epithelial cells had highly atypical nuclei, the lesion was diagnosed as IPMN with high grade dysplasia. Immunohistochemistry showed that the IPMN component showed to be MUC2-, MUC5AC-, and CDX2-positive but MUC1- and MUC6-negative. Mutational analyses using genomic DNA revealed that the IPMN component had a mutation of GNAS at exon 8 (Arg201Cys).ConclusionWe finally diagnosed this case as gastric ectopic pancreas accompanied by intestinal type IPMN with high grade dysplasia possessing GNAS mutation. Although there were 17 cases of ectopic pancreas with IPMN including 6 cases of gastric ones reported in the English literature, this is the first case of ectopic pancreas with IPMN which was proved to have GNAS mutation. Intimate preoperative examinations including imaging analyses and EUS-FNA biopsy/cytology are recommended to decide whether the lesion has to be resected or not even if they are not effective for getting the right diagnosis.

Characteristics and optimal ablation settings of a novel, contact-force sensingand local impedance-enabled catheter in an ex vivo perfused swine ventricle model.

Local impedance (LI) has emerged as a new technology that informs on electrical catheter-tissue coupling during radiofrequency (RF) ablation. Recently, IntellaNav StablePoint, a novel LI-enabled catheter that equips contact force (CF) sensing, has been introduced. Although StablePoint and its predecessor IntellaNav MiFi OI share the common technology that reports LI, distinct mechanics for LI sensing between the two products raise a concern that the LI-RF lesion formation relationship may differ. In an ex vivo swine cardiac tissue model, we investigated the initial level and range of a reduction in LI during a 60-sRF ablation and the resultant lesion characteristics at nine combinations of three energy power (30, 40, and 50 W) and CF (10, 30, and 50 g) steps. Correlations and interactions between CF, LI, wattage, and formed lesions were analyzed. Incidence of achieving LI drop plateau and that of a steam pop were also determined. Positive correlations existed between CF and initial LI, CF and absolute/relative LI drop, CF and lesion volume, and LI drop and lesion volume. At the same LI drop, wattage-dependent gain in lesion volume was observed. Steam pops occurred in all CF steps and the prevalence was highest at 50 W. LI drop predicted a steam pop with a cutoff value at 89Ω. In StablePoint, wattage crucially affects LI drop and lesion volume. Because 30 W ablation may by underpowered for intramural lesion formation and 50 W often resulted in a steam pop, 40 W appears to achieve the balance between the safety and efficacy.

Technical Accuracy and Efficiency of Magnetic Resonance Imaging in Evaluation of Uterine Masses in Comparison with Ultrasound

Aim of the Study: comparing accuracy, sensitivity and specificity of the magnetic resonance imaging and ultrasound in differentiating and characterizing of uterine masses.Patients and Method: A prospectively studied has been conducted on 41 female patients with suspected uterine masses. They were subjected to ultrasound and magnetic resonance imaging (MRI) examination. Comparison has been performed between modalities to detect and characterize all masses. Statistical parameters that include the specificity, sensitivity, accuracy and positive and negative predictive value have been estimated for the two modalities in all of the uterine masses.Results: Among 41 female patients, majority were diagnosed as leiomyoma 28 (68%), cervical cancer 1 (2%), adenomyosis 7 (17%), endometrial polyp 2 (5%), endometrial carcinoma 2 (5%) and normal 1 patient (2%). Totally 3 (i.e. 7%) patients have been found malignant while 37 (i.e. 93%) have been found benign. For detection of myometrial mass (leiomyoma), the sensitivity between the ultrasound and MRI is 100%, accuracy was (ultrasound: 92% and MRI: 100%). In the classification of myometrial mass (i.e. leiomyoma) site, sensitivity between the ultrasound and MRI has been 21% and 92% respectively and specificity was (ultrasound: 0 and MRI: 100%). All intramural and subserosal lesions are seen in MRI. For picking up degeneration within the leiomyoma MRI are more useful. There have been considerable differences in the diagnosis of the adenomyosis by the MRI in comparison with ultrasound with sensitivity was (MRI: 100% and ultrasound: 71%), and specificity for both was 100%, whereas accuracy was 75% for ultrasound and 100% for MRI. In the detection of the endometrial carcinoma, the MRI has achieved 100% sensitivity and 50% specificity whereas ultrasound had zero sensitivity and specificity was 50%. Among two cases of endometrial polyp, one patient is diagnosed correctly by ultrasound &amp; MRI, the sensitivity for both was 50% and accuracy was (ultrasound: 50% and MRI: 75%). MRI and ultrasound was correctly diagnosis of one patient with cervical cancer with sensitivity and accuracy 100%.

A rare case of endosalpingiosis masquerading as a pedunculated subepithelial colonic nodule: utility of EUS and endoscopic resection

A 54-year-old woman was found to have a nonobstructing pedunculated submucosal lesion 24 cm from the anal verge during a routine screening colonoscopy (A). CT imaging revealed a 1.8-cm irregular plaque-like lesion within the rectosigmoid area, without any lymphadenopathy. EUS showed a 11.6 × 7.7 mm polypoid intramural (subepithelial) lesion in the sigmoid colon, predominantly cystic and anechoic and originating from the submucosa (layer 3), with well-defined borders, and an intact interface between the lesion and the muscularis propria (layer 4) (B).

S3239 Evaluation of Sensitivity and Diagnostic Accuracy of Endoscopic Ultrasound for Diagnosis of Solid Pancreatic Lesions

INTRODUCTION: Endoscopic ultrasonography with fine needle aspiration/biopsy (EUS-FNA/FNB) facilitates a minimally invasive approach to obtaining pancreatic tissue for the workup of possible malignancies. The American Society of Gastrointestinal Endoscopy (ASGE) has set the benchmark for EUS-FNA/FNB to have a diagnostic rate of >75% and a sensitivity of >85% for solid pancreatic masses. The aim of this study is to assess the real-world rates of diagnostic accuracy, sensitivity and specificity of EUS-FNA for solid pancreatic masses, and factors associated with higher accuracy and sensitivity. METHODS: We conducted a retrospective chart review of all adult patients who underwent EUS-FNA/FNB at an academic level-1 trauma center in southeastern New England between April 2015 and March 2020. Patients were selected based on CPT billing codes for EUS with FNA/FNB. The primary outcomes were diagnostic accuracy and sensitivity, and these were stratified based on several intraprocedural factors including tumor size and number of passes. Samples with pathology reports of atypia without confirmed malignancy were considered non-malignant. RESULTS: Of 204 patients who underwent EUS with FNA/FNB, 38 were done for solid pancreatic masses. 166 patients were excluded due to cystic lesions (49) and 117 were done for intramural lesions or EUS-liver biopsy. For solid masses, the mean maximum tumor diameter was 26.9mm, with 46% occurring in the head or uncinate process (Table 2). The mean number of passes was 2.39 and 87% were done with a 22-gauge needle. On-site cytopathology was present for 37% of cases and 21% were done with general anesthesia. 53% had a duodenal approach. The overall diagnostic rate was 95%. Sensitivity for pancreatic malignancy was 85% and specificity was 100%. Sensitivity and diagnostic rates are higher with increasing tumor size, 2-4 needle passes vs 2-3 passes, and for masses in the pancreatic tail vs neck (Table 2). CONCLUSION: he diagnostic accuracy and sensitivity of EUS-FNA/FNB for solid pancreatic lesions were 95% and 85%, respectively, at our institution, thus meeting the ASGE grade 1C guidelines, despite fewer passes and less on-site cytopathology presence compared with larger studies[2].Table 1.: Demographics of patients with solid pancreatic tumorsTable 2.: Subgroup analysis by needle size, number of passes, tumor stage and approach (trans-gastric vs. trans-duodenum)