Malignant Gastric Ulcer Research Articles

Emerging functions of lycopene in the management of digestive premalignant lesions.

Common digestive precancerous lesions, including oral potentially malignant disorders (OPMDs), gastric ulcers and colorectal adenoma, harbor high risk of cancerous transformation. Early intervention of these lesions is significant to prevent carcinogenesis and improve patients' prognosis. Lycopene, a carotenoid predominantly accumulated in tomatoes, is clinically recommended with its cis structure; as lycopene harbors the most potent antioxidative effects among carotenoids, its chemopreventive effects on the premalignant lesions is noted. Despite several reviews have assessed lycopene's efficacy for OPMDs, emerging studies have reported varying efficacy for digestive precancerous lesion with no comprehensive summary. Therefore, this review initially evaluates the efficacy and underlying mechanisms of lycopene for management of digestive precancerous lesions. According to the included studies, lycopene may show high promise in the management of digestive precancerous lesions, such as relieving mouth opening and burning sensation of oral submucous fibrosis (OSF), presenting potentially equivalent efficacy on managing oral lichen planus (OLP) as steroids and alleviating gastrointestinal precancers' symptoms, meanwhile lowering colon cancer risk. Moreover, its mechanisms for managing digestive precancerous lesions are concretely summarized, including anti-oxidative stress effects, anti-inflammatory response and regulation of cell proliferation and apoptosis, especially its modifications on TLR4/TRIF/NF-κB signaling pathway and p53-dependent cell cycle control and apoptosis. More studies are warranted to confirm its long-term efficacy and preventive role against malignant transformation of digestive precancerous lesions as evidence is insufficient.

S2797 Closing the Gap: First Report of Endoscopic Suture Closure of Malignant Gastric Hemorrhage

Introduction: Gastrointestinal bleeding secondary to luminal malignancy is typically difficult to manage with conventional endoscopic therapies. Endoscopic suturing devices have become increasing popular for the management of various resection defects, inadvertent perforations, and bariatric endosurgery. Limited recent data suggests that this technology is effective for refractory bleeding from benign peptic ulcer disease. Herein we describe a case of the successful endoscopic closure of a bleeding malignant gastric ulcer using endoscopic suturing. Case Description/Methods: A 60-year-old male with a past history of primary thrombocytopenia, and recent diagnosis of signet ring gastric adenocarcinoma/linitis plastica (T2, N2, M0) on FLOT chemotherapy (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel) presented with hematemesis and acute on chronic anemia. Physician examination was notable for tachycardia and hypotension. Laboratory evaluation was notable for a hemoglobin of 7.8 g/dL from 15.0 g/dL four days prior. The patient was intubated and urgent upper endoscopy in the intensive care unit was performed which showed active oozing and bleeding from a cratered gastric ulcer (previously biopsy proven adenocarcinoma) on the proximal lesser curvature measuring approximately 20 mm in size (A). Diffuse thickening of gastric folds consistent with linitis plastica was also seen. Initial attempts with bipolar cautery and epinephrine injection were unable to achieve hemostasis. An endoscopic suturing system was employed to place a suture in a figure of eight fashion and cinched at end with closure of the ulcer bed (B). The ulcer bed was not visible after suturing and hemostasis was achieved (C). Repeat upper endoscopy after two weeks for nasojejunal feeding tube placement did not show presence of ulcer and any recurrent bleeding. Patient is being clinically optimized to resume chemotherapy. Discussion: To our knowledge, we describe herein the first case of successful use of endoscopic suturing for closure of a bleeding malignant gastric ulcer. We hypothesize that the thickened gastric folds secondary to the histologic nature of linitis plastica allowed for adequate tissue purchase at the margins of the bleeding gastric ulcer which would typically be precluded in malignant tissue due to its friable nature.Figure 1.: A: Endoscopic image of gastric adenocarcinoma and associated cratered ulcer with oozing hemorrhage. B: Endoscopic image of suture device during closure. C: Endoscopic image of successful approximating edges of ulcer after endoscopic suturing without evidence of bleeding.

Determining the Endoscopic Follow-Up for Gastric Ulcers Based Upon Endoscopic Appearance and Histology (Poster Presentation)

Gastric ulcers are common, but the prevalence rate of malignancy in endoscopically diagnosed gastric ulcers varies considerably. It is unclear whether endoscopic follow-up is warranted in all patients with gastric ulcers, as the yield of the follow-up endoscopy is very low, especially in the setting when histology shows benign features. We performed a quality improvement project to determine the diagnostic accuracy of combined endoscopic and histologic features in differentiating benign from malignant gastric ulcers vs endoscopic features only and to avoid over-use of endoscopic evaluation of ulcer healing for benign cases.

An xception model based on residual attention mechanism for the classification of benign and malignant gastric ulcers

To explore the application value of convolutional neural network combined with residual attention mechanism and Xception model for automatic classification of benign and malignant gastric ulcer lesions in common digestive endoscopy images under the condition of insufficient data. For the problems of uneven illumination and low resolution of endoscopic images, the original image is preprocessed by Sobel operator, etc. The algorithm model is implemented by Pytorch, and the preprocessed image is used as input data. The model is based on convolutional neural network for automatic classification and diagnosis of benign and malignant gastric ulcer lesions in small number of digestive endoscopy images. The accuracy, F1 score, sensitivity, specificity and precision of the Xception model improved by the residual attention module for the diagnosis of benign and malignant gastric ulcer lesions were 81.411%, 81.815%, 83.751%, 76.827% and 80.111%, respectively. The superposition of residual attention modules can effectively improve the feature learning ability of the model. The pretreatment of digestive endoscopy can remove the interference information on the digestive endoscopic image data extracted from the database, which is beneficial to the training of the model. The residual attention mechanism can effectively improve the classification effect of Xception convolutional neural network on benign and malignant lesions of gastric ulcer on common digestive endoscopic images.

794 Diagnostic Pitfall in Atypical Presentation of Malignant Gastric Ulcer Perforation

Abstract Background Peptic ulcer perforation is one of the most common surgical problems in daily practice. Although it can be easily diagnosed clinically, the clinical presentation can be less obvious in some cases leading to diagnostic pitfalls and mortality. This case report aims to highlight an atypical presentation of malignant gastric ulcer perforation in a patient with chronic abdominal pain. Case presentation A 78-year-old lady presented with chronic abdominal pain for 3 months. Investigations and imaging revealed T2N1M0 malignant gastric ulcer which was confirmed by endoscopy. Due to her low body mass index and underlying comorbidities, she was admitted for pre-operative optimization. However, she was a good 78 with the clinical frailty scale 4 and the National Early Warning Score 0 throughout the stay. On the night before the operation, she suddenly developed delirium. Further history revealed marked oliguria for 12 hours. There was mild abdominal distension without peritonism. She was catheterized and treated with fluids and antibiotics. X-ray suggested massive pneumoperitonium. Subsequently, she developed full-blown septic shock with rapid clinical deterioration within 3 hours. With the estimated Boey scoring of 3 and rapid clinical deterioration, the symptom control approach was decided. A palliative bedside ascitic tap was performed to relieve the discomfort. Four hours after the onset, unfortunately, the patient passed away. Conclusions Although gastric ulcer perforation usually presents with obvious symptoms, extra precaution should be exercised in elderly patients with chronic abdominal pain and comorbidities. We could learn that routine monitoring of urine output might aid in the early diagnosis of sepsis.

Biopsy in emergency gastroscopy does not increase the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding combined with suspected malignant gastric ulcer: a multicenter retrospective cohort study

BackgroundFew studies have reported whether a biopsy in emergency gastroscopy (EG) increased the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) combined with suspected malignant gastric ulcer (SMGU). This study aims to conduct a multicenter retrospective cohort study using propensity score matching to verify whether a biopsy in EG increases the risk of rebleeding in patients diagnosed with Forrest I ANVUGIB combined with SMGU.MethodsUsing the data for propensity-matched patients, logistic regression models were fitted using rebleeding as the dependent variable. Survival time was defined as the length of time the patient experienced from visiting the emergency department to rebleeding. We used the Kaplan–Meier (KM) method to analyze the 30-day survival of the patients with and without a biopsy after matching, and the log-rank test was performed to examine the differences in survival.ResultsWith the use of propensity score matching, 308 patients who underwent a biopsy in EG were matched with 308 patients who did not. In the five logistic regression models, there were no significant group differences in the risk of rebleeding in patients with Forrest I ANVUGIB combined with SMGU between the biopsy and no-biopsy groups. The probability of survival was not significantly different between the no-biopsy and biopsy groups.ConclusionsIn this multicenter, retrospective propensity score matching cohort study, compared with patients without a biopsy, patients with a biopsy during EG had no increased risk of rebleeding, and there was no significant difference in the rate of rebleeding.

Gastropleural Fistula in a Child with Acute Lymphoblastic Leukemia Due to Perforated Gastric Ulcer.

Gastropleural fistula (GPF) is a pathological communication between stomach and pleural cavity. GPF is described rarely in adults following bariatric surgery, iatrogenic perforations, complicated empyema thoracis, penetrating chest trauma, perforated malignant gastric ulcers, and invasive tumors. GPF in children is extremely rare. The authors describe a female child with leukemia, who presented with left-sided pneumonia and chylothorax. After a delay of around 3 wk she was diagnosed with GPF, which was due to a perforated gastric ulcer induced by high-dose steroids which she was receiving as chemotherapy. She was managed with repair of GPF and had a favorable outcome.

Differentiation Between Malignant and Benign Endoscopic Images of Gastric Ulcers Using Deep Learning.

Background and AimEndoscopic differentiation between malignant and benign gastric ulcers (GU) affects further evaluation and prognosis. The aim of our study was to evaluate a deep learning algorithm for discrimination between benign and malignant GU in a database of endoscopic ulcer images.MethodsWe retrospectively collected consecutive upper gastrointestinal endoscopy images of GU performed between 2011 and 2019 at the Sheba Medical Center. All ulcers had a corresponding histopathology result of either benign peptic ulcer or gastric adenocarcinoma. A convolutional neural network (CNN) was trained to classify the images into either benign or malignant. Endoscopies from 2011 to 2017 were used for training (2011–2015) and validation (2016–2017). Hyper-parameters, image augmentation and pre-training on Google images obtained images were evaluated on the validation data. Held-out data from 2018 to 2019 was used for testing the final model.ResultsOverall, the Sheba dataset included 1978 GU images; 1894 images from benign GU and 84 images of malignant ulcers. The final CNN model showed an AUC 0.91 (95% CI 0.85–0.96) for detecting malignant ulcers. For cut-off probability 0.5, the network showed a sensitivity of 92% and specificity of 75% for malignant ulcers.ConclusionOur study displays the applicability of a CNN model for automated evaluation of gastric ulcers images for malignant potential. Following further research, the algorithm may improve accuracy of differentiating benign from malignant ulcers during endoscopies and assist in patients’ stratification, allowing accelerated patients management and individualized approach towards surveillance endoscopy.

Bleeding malignant gastric ulcer: successful endoscopic hemostasis with an over-the-scope clip.

Bleeding malignant gastric ulcer: successful endoscopic hemostasis with an over-the-scope clip.

Diagnostic value of platelet indices, carbohydrate antigen 19-9 and carcinoembryonic antigen in differentiating malignant from benign gastric ulcers

Objective To elucidate the value of platelet indices, carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) in differentiating malignant from benign gastric ulcers. Background Gastric cancer is one of the most common malignant diseases and benign gastric ulcer is a worldwide disease, responsible for substantial premature mortality. Clinical symptoms of early gastric cancer could not be used to distinguish gastric cancer from ulcers. Platelet indices: mean platelet volume (MPV) and platelet distribution width (PDW) are a group of platelet parameters investigated as platelet activation indicators. Patients and methods This prospective study included 150 patients: 30 patients with malignant gastric ulcer, 60 patients with benign gastric ulcer, and 60 healthy control participants. Upper endoscope with tissue biopsy and pathological evaluation, Helicobacter pylori stool antigen, platelet count, PDW, MPV, CEA, CA 19-9, computed tomography scan of the chest, abdomen, and the pelvis were assessed. Results Platelet count, MPV, PDW, CEA, and CA 19-9 were significantly higher in malignant gastric ulcer patients than benign ulcer patients and controls. MPV and PDW showed sensitivity, specificity, and area under the curve (93.3, 70 and 0.934% and 96.7, 86.7 and 0.966%, respectively) in predicting malignancy in gastric ulcer patients with improved diagnostic accuracy when combined with CEA and CA 19-9. Higher platelet count and PDW were significantly associated with advanced clinicopathological parameters of gastric cancer. Conclusion Changes in platelet indices are valuable markers in predicting malignancy in gastric ulcer patients. Significant increase in platelet count and PDW correlate and could be reliable markers, together with other markers of gastric cancer (CEA and CA 19-9), for clinicopathological features of malignant gastric ulcer.

Giant gastric ulcers: Malignancy yield and predictors from a 10-year retrospective single centre cohort.

Gastric cancer is known to reside in some gastric ulcers but what predicts this association is still unclear. Historically it has been thought that the increasing size of gastric ulcers may be a predictor for harbouring malignancy. Giant gastric ulcers are arbitrarily defined as ≥3 cm. The aim of this retrospective study was to examine patients with giant gastric ulcers within a single tertiary centre over a 10-year period. Our primary outcomes included the malignancy yield in giant gastric ulcers and to determine if any demographic, clinical or endoscopic predictors for malignancy exist. Secondary outcomes included the 30-day and 12-month mortality. Patients with giant gastric ulcers ≥3 cm presenting from September 2005 to December 2015 were included in the study. Malignancy yield was obtained by looking at histology reports. Predictors for malignancy were tested using binary logistic regression, after demographic, clinical and endoscopic variables were tested using univariate analysis and for collinearity. A cohort of 111 patients was included for the final analysis. Forty-two giant gastric ulcers were malignant, equating to a yield of 37.8% (95% CI 28.8-46.8). Binary logistic regression revealed predictors for malignancy included: ulcer location being within the fundus, cardia or incisura (odds ratio (OR) 4.417; 95% CI 1.10-17.76; P = 0.036); younger age of patient (OR 0.202; 95% CI 0.06-0.71; P = 0.013); and endoscopic 'non-suspicion' (OR 0.138; 95% CI 0.049-0.39; P < 0.001). Patient's 12-month mortality for giant gastric ulcer was 61.9% (26/42) for malignant and 21.9% (11/73) for benign histology. We have shown a high malignancy yield of 37.8% (95% CI 28.8-46.8) and a 12-month mortality of 61.9% for malignant giant gastric ulcers and 21.9% for benign giant gastric ulcers. Predictors for malignancy in patients with giant gastric ulcers include ulcer location, patient's age and endoscopist's 'suspicion' during endoscopy.

Post tubercular gastropulmonary fistula: A rare complication

Gastropulmonary fistulas are themselves a very rare clinical entity and very less has been written about them in literature. Most of the cases listed in literature till now show that most of the gastropleural fistulas have been reported after intrathoracic gastric perforation in hiatal hernia, traumatic diaphragmatic hernia with later gastric perforation, perforated malignant gastric ulcer at fundus, extension of subphrenic abscess with gastric perforation, pulmonary resection and gastric bypass operations and only a single case has been documented till now regarding post intercostal chest tube drainage gastropulmonary fistula in tubercular patient.Here we present a first of its kind case where a middle aged female developed gastropulmonary fistula on the left side after multiple pleural aspirations for tubercular pleural effusion. The patient was operated and left lower lobectomy was done with the resection of involved part of stomach and fistulous tract from the left posterolateral thoracotomy.

The usefulness of endoscopic ultrasonography in differentiation between benign and malignant gastric ulcer.

Gastric ulcer may be benign or malignant. In terms of therapy and patient’s prognosis early detection of malignancy is very important. The aim of this study was to assess the usefulness of endoscopic ultrasound (EUS) in differentiation between benign and malignant gastric ulcer. A prospective study included 20 consecutive adult patients with malignant gastric ulceration and 20 consecutive adult patients with benign gastric ulceration. All the patients underwent EUS. A total of 6 parameters were analyzed: ulcer width, ulcer depth, the thickness of the gastric wall along the edge of ulceration (T0), the thickness of the gastric wall 2 cm from the edge of ulceration (T2), loss of layering structure of the gastric wall, and the presence of regional lymph nodes. EUS criteria for malignancy and a point-score of malignancy were defined. The critical value of total point-score was also calculated showing the best reliability parameters. There are 4 criteria for malignancy of gastric ulceration: T0 > 10 mm, T2 > 5 mm, EUS visualization of at least one lymph node, loss of layering structure of the gastric wall. Furthermore, T2 > 5 mm was the only EUS independent predictor of ulcer malignancy. The total point score of ≥ 4 was the cut-off pointscore value which gave the best reliability parameters in the assessment of malignant ulcers: sensitivity of 70%, specificity of 95%, positive predictive value of 93.3%, negative predictive value of 76% and accuracy of 82.5%. According to the results obtained in this study, we can conclude that EUS is usefull in differentiation between benign and malignant gastric ulcer.

Clinical significance of tissue trefoil factor 1 protein and serum pepsinogen levels in differentiation of benign and malignant gastric ulcers

Clinical significance of tissue trefoil factor 1 protein and serum pepsinogen levels in differentiation of benign and malignant gastric ulcers

Eosinophilic gastroenteritis mimicking as a malignant gastric ulcer with lymphadenopathy as shown by computed tomography and endoscopic ultrasound.

Eosinophilic gastroenteritis mimicking as a malignant gastric ulcer with lymphadenopathy as shown by computed tomography and endoscopic ultrasound.

P-0019 - Endoscopy Research Opportunities in Differential Diagnosis of Malignant Gastric Ulcer

P-0019 - Endoscopy Research Opportunities in Differential Diagnosis of Malignant Gastric Ulcer

The usefulness of ulcer size and location in the differential diagnosis of benign and malignant gastric ulcer

Gastric cancer can present as a gastric ulcer, which can mimic a benign gastric ulcer. In this study, we aimed to investigate the value of gastric ulcer size and location in the differential diagnosis of benign and malignant gastric ulcers. We reviewed retrospectively the upper endocopic findings of 14,400 patients between April 2008 and March 2010. Total 276 patients with gastric ulcers were divided into two groups according to histopathological examination. Ulcer location, size, age, and gender were compared between the two groups. The predominant region of ulcer location was the corpus for the malignant ulcer group and the antrum for the benign ulcer group. The malignant ulcer ratios according to region in the whole group were: cardia 19 ulcers with 14 malignant (73.68 %), corpus 70 ulcers with 38 malignant (54.2 %), angulus 45 ulcers with 6 malignant (13.3 %), and antrum 142 ulcers with 20 malignant (14.8 %), respectively. The median size of ulcer was significantly higher in the malignant ulcer group compared with the benign ulcer group (p < 0.001). These results suggest that the location and diameter of gastric ulcers may be used as a marker of risk factors for developing gastric cancer.

Erythropoietin Antibody-Positive Pure Red Cell Aplasia Diagnosed after Surgical Intervention for Malignant Gastric Ulcer Bleeding

혈액투석 환자에서 빈혈의 주요 원인은 에리트로포이에틴 생성 장애이며 이에 대한 치료로 재조합 인 에리트로포이에틴이 널리 사용되고 있다. 이러한 치료에 저항성을 보이는 경우 만성 출혈 등에 의한 철분 부족을 우선적으로 고려해야 하지만 원인질환을 교정한 후에도 적혈구 수혈이 필요할 정도로 빈혈이 지속된다면 에리트로포이에틴 항체 형성에 의한 순수 적혈구 무형성증을 감별하기 위한 에리트로포이에틴에 항체 및 골수 조직검사 등이 적극적으로 이루어져야 할 것으로 보인다.

Expression and significance of trefoil factor 1 protein and serum pepsinogen in benign and malignant gastric ulcers

To explore the clinical significance of trefoil factor 1 (TFF1) protein expression and serum pepsinogen (PG) concentration in benign and malignant gastric ulcers. The TFF1 protein expression was evaluated by immunohistochemistry in biopsies of gastric mucosa from 18 normal controls, 25 patients with gastric ulcer and 13 patients with ulcerative gastric cancer at our hospital during January to June 2011. The serum concentrations of PGI and PGII were detected by enzyme-linked immunosorbent assay (ELISA) and PG/PGII (PGR) was subsequently calculated. The expression of TFF1 protein increased significantly in ulcerative and peripheral gastric mucosa and peripheral mucosa of gastric cancers versus that in normal controls and the ulcerocancer group (3.04% ± 0.20%, 3.00% ± 0.20%, 3.23% ± 0.26% vs 1.67% ± 0.18%, 0.46% ± 0.18%, all P < 0.01). The elevated expression of TFF1 increased the risk of gastric ulcer (OR: 1.365, 95%CI: 1.065 - 1.749, P = 0.014) while the down-regulation of TFF1 significantly increased the risk of ulcerocancer (OR: 3.067, 95%CI: 1.391 - 6.757, P = 0.005). The serum levels of PGI and PGII in gastric ulcer group were significantly higher than that in normal control and ulcerocancer group ((150 ± 27), (28 ± 9) vs (121 ± 22), (17 ± 7), (79 ± 12), (20 ± 5) µg/L,all P < 0.01). The PGI level and PGR decreased significantly in the ulcerocancer group versus normal control (both P < 0.01). But there was no statistical difference in PGII (P > 0.05). Receiver operating characteristic curve analysis revealed that PGI and PGR were valuable for the diagnosis of malignant gastric cancer with an area under curve of 0.975 and 0.914 respectively. The expression of TFF1 protein increases in gastric ulcer but decreases in gastric ulcerocancer. The elevated serum levels of PGI and PGII indicate benign ulcer while a marked decline of serum PG I and PGR serves as a risk signal of malignant gastric ulcer. The evaluation of expression profiles of TFF1 protein and PGs is helpful for the differentiation of benign gastric ulcer from malignant ulcerocancer.

Differential diagnosis between benign and malignant ulcers: 320-row CT virtual gastroscopy

This study aims to assess the diagnostic accuracy of virtual gastroscopy obtained by 320-row computed tomography (CT) examination in differentiating benign from malignant gastric ulcers (GUs). 49 patients (30 M, 19 F, mean age 58.6) with endoscopic and histological diagnosis of GU underwent CT examination. A hypotonizing drug was administered and gastric walls were distended by air in order to perform virtual endoscopy. Based on morphological features, GUs were subdivided into benign or malignant forms by two blinded radiologists. Interobserver agreement was evaluated using Cohen’s kappa (κ) test. CT results were then compared with endoscopic and histological findings, having the latter as the reference standard. Thirty-five out of 49 patients (71%) were affected by malignant ulcers, while in the remaining 14 cases diagnosis of benign GU was made. Virtual gastroscopy showed diagnostic accuracy, sensitivity, and specificity values of 94%, 91%, and 100%, respectively, in differentiating benign from malignant ulcers. Almost perfect agreement between the two readers was found (κ = 0.86). CT virtual gastroscopy improves the identification of GUs and allows differentiating benign from malignant forms.