Mass In Fundus Research Articles

S2691 A Rare Presentation of Gastric Plastocytomas in a Patient With Multiple Myeloma

Introduction: Multiple myeloma is an uncommon hematological neoplasm. This malignancy involves unchecked plasma cell growth in the bone marrow, but in a subset of often more advanced cases, these cells may migrate to soft tissues causing extramedullary plasmacytoma. This is unusual, and, in the literature, few cases of extramedullary plasmacytomas involve the gastrointestinal tract. Within this system, the more common locations are the stomach, the liver, the large bowel, and more rarely, the small bowel. Case Description/Methods: A 59-year-old male with a medical history of chronic hepatitis C, and Stage III multiple myeloma status post four cycles of chemotherapy presented with altered mental status. Upon evaluation, he had significant electrolyte abnormalities, remarkable anemia, severe renal and liver dysfunction, and a positive hemoccult test. Our patient received intravenous fluid, and multiple blood products. He was then admitted to the intensive care unit for a high level of care. On the second day of admission, he developed new onset hematemesis, and the gastroenterology team was consulted. The patient was started on a pantoprazole drip. Urgent esophagogastroduodenoscopy showed several polypoid appearing masses with overlying ulceration in the gastric fundus (Figure a &b), and tissue biopsies were obtained. Biopsy result of the polypoid fundal mass showed a large cell neoplasm with plasmocytic differentiation. Gastric tissue sections showed an ulcerated lesion with submucosal, tightly packed atypical large cells with multinucleation, prominent nucleoli and relatively identifiable mitoses (Figurec). A panel of immunohistochemical stains with plasma cell markers were positive for kappa, Multiple Myloma-1 nuclear protein, and CD138 (Figure d-f). The overall findings were compatible with gastric involvement by a plasma cell neoplasm. Discussion: This case highlights a complicated, yet a uniquely rare presentation of extramedullary plasmacytoma in a patient diagnosed with multiple myeloma. Although the gastrointestinal tract is rarely involved in patients with multiple myeloma, it should be considered as the differential diagnosis in patients with gastrointestinal bleeding especially with a known concurrent systemic hematological malignancy. The presence of gastrointestinal involvement and the malignant phase of multiple myeloma are associated with a poor prognosis despite aggressive therapy, and it is therefore paramount to establish an accurate diagnosis early to avoid any delays in treatment.Figure 1.: (a,b) EGD shows polypoid EMP in the gastric fundus. (c) Infiltration of plasmablasts with highly atypical nuclei and prominent nucleoli (hematoxylin-eosin 20x). (d) Granular positivity for kappa immunoglobulin light chain. (e) Positive immunostaining for MUM-1. (f) Positive CD138 immunostaining highlights the plasma cells in the lamina propria of the gastric fundus EMP.

S2576 Application of Hemospray for Metastatic Bleeding Gastric Adenocarcinoma: A Case Report

Introduction: TC-325 hemostatic powder (Hemospray) is a mineral-based topical agent that acts as a mechanical barrier over a bleeding site. It is a non-invasive, safe, and effective modality in controlling active GI bleeding, with immediate response. Here, we present a case of bleeding metastatic gastric adenocarcinoma managed with Hemospray after the failure of standard endoscopic therapy. Case Description/Methods: A 64-year-old male presented to the emergency room (ER) for symptomatic anemia. His hemoglobin was 4.6 g/dL. CT imaging showed gastric cardia lesion with multiple hepatic metastases. After blood transfusion, EGD (Figure 1a) showed a cardia lesion with oozing blood from multiple sites. Endoscopic ultrasound with fine-needle aspiration, showing atypical cells. The patient continued to have melena requiring transfusions. CT angiogram was negative. Partial gastrectomy was not performed due to peritoneal carcinomatosis. Endoscopic hemostasis with epinephrine and clips failed (Figure 1b). Hemospray was deployed (Figure 1c) with an immediate response. Later patient underwent left gastric artery embolization (Figure 1d), liver biopsy and peritoneal node sampling that suggested metastatic adenocarcinoma with primary gastric malignancy. The patient and his family opted for palliative care and was discharged. Discussion: Gastric cancer accounts for 2-8% of overall UGIB and 58% bleeding risk compared to other GI malignancies. There are no specific guidelines and only limited evidence was available on managing malignancy-related UGIB. Nonresponsive, inoperable metastatic gastric cancer bleeding is challenging and extremely difficult to manage using conventional hemostasis techniques. Based on our case, we recommend utilizing Hemospray as a first-line, monotherapy or in combination to control bleeding until a definitive treatment, reducing morbidity and mortality.Figure 1.: (A) Submucosal gastric fundal mass distal to gastroesophageal junction with blood oozing from multiple sites (arrows), (B) Image showing endoscopic hemostatic clips placement (arrowheads), (C) Application of Hemospray over the Gastric Mass after unsuccessful attempts using standard-of-care hemostatic methods, (D) Showing embolization of the left gastroepiploic artery.

Image case: Gastric tuberculosis

35 years old male presented by recurrent hematemesis attacks and recurrent blood transfusion, no history of cough, with history of anti-tuberculosis therapy for pulmonary TB 2 years ago. General examination revealed pallor, emaciated, no lymphadenopathy, local examination showed epigastric tenderness and no organomegaly, and examination of other systems was unremarkable. Haemglobolin was 8 gm% (normocytic normochromic), chest X ray and abdominal ultrasound were free. Upper gastrointestinal endoscopy revealed ulcerated fundal mass. Endoscopic biopsies revealed caseating granulomas by histopathology examination. Discussion Gastrointestinal tuberculosis is a rare disease, presented mainly in the ileoceceal region. Mycobacterium tuberculosis infection in the stomach is similar to gastric carcinoma manifestations. Gastric TB is mainly secondary to pulmonary TB. Antrum and prepyloric area is the most common sites affected. Gastric tuberculosis is mainly existed as ulcerative followed by hypertrophic lesions. GTB diagnosis can be established by detection of acid fast bacilli and/or caseating granuloma in gastric mucosa or submucosa. Chemotherapy is mainly give good results, while surgery may be needed in gastric outlet obstruction cases.

Heterotopic pancreas presentation as a fundal submucosal mass, a case report

Heterotopic pancreas is a rare submucosal lesion and generally an incidental finding. The important differential diagnosis is mesenchymal submucosal neoplasm. Here, we present a case with heterotopic pancreas presentation as a fundal submucosal mass. A 35-year-old male was admitted to our hospital due to a 9-month history of abdominal pain and fullness. Physical examinations and laboratory findings were normal. Esophagogastroduodenoscopy was performed. The patient underwent exploratory laparotomy and wedge resection of the stomach. The patient was symptom free 17 months later. Esophagogastroduodenoscopy revealed a fundal mass. Histopathological examination confirmed ectopic pancreatic tissue involving submucosa and muscularis propria. Our case report demonstrates a very rare cause of fundal submucosal mass with abdominal pain and fullness. The physicians at major gastrointestinal referral centers are much more likely to be familiar with heterotopic pancreas and its clinical manifestation.

Synchronous cholangiocarcinoma and gallbladder cancer: A rare presentation

Introduction: Synchronous biliary tree and gallbladder cancers are rarely encountered and reported in the literature. In this article, we report an extremely rare presentation of a patient with distal common hepatic duct (CHD), proximal common bile duct (CBD) and gallbladder cancer associated with anomalous pancreaticobiliary duct junction (APBDJ) as primary tumors. Case Report: A 40-year-old male referred to us with RUQ pain, fever, jaundice and pruritis since two weeks. PET-CT showed hypermetabolic polypoid mass in the fundus of gallbladder and a periportal node. ERCP was done but guide wire could not be passed beyond mid CBD. The findings were neoplastic mass in fundus of the gallbladder with pericholedochal lymphadenopathy. There was another neoplastic mass in the CBD. An extended cholecystectomy with extrahepatic CBD excision with a pancreaticoduodenectomy with radical lymphadenectomy was performed. Intra-operative ultrasonography was done to rule out other lesions in the pancreas and liver. Histopathological examination revealed well differentiated adenocarcinoma of gallbladder and adenocarcinoma of proximal CBD and distal CHD, stagging pT2 pN0 pMx. Conclusion: Synchronous extra hepatic and gallbladder tumors are extremely rare, their etiopathogenesis has not been properly understood and defined. Biliary cancers with PBM are thought to develop multicentrally, due to the effect of pancreatic juice reflux on the mucosa of the biliary tract.

Fever,Weight Loss and Early Satiety due to Gastric Inflammatory Myofibroblastic Tumor; Case Report and Literature Review

Gastric inflammatory myofibroblastic tumor (IMT) is a rare tumor with and unpredictable prognosis usually find in young adults. We present an 18-yearold man with gastric IMT. He complained of epigastric pain, intermittent fever and night sweating associated with weight loss since two years ago. Physical examination showed anemic and cachestic features with mild abdominal tenderness in palpitation as well as an abdominal mass in epigastrium. Abdominal CT scan revealed a huge mass that was arising from the stomach. Upper endoscopy revealed a submucosal lesion in fundus of stomach of approximately 8cm. Endoscopic ultrasound showed a large sub-mucosal non homogenous fundal mass with areas of calcification. The patient underwent laparoscopic partial gastrectomy. Histopathologyand immunohistochemistryevaluation revealed an IMT.

Gastric Metastasis of Hepatocellular Carcinoma With Gastrointestinal Bleeding After Liver Transplant: A Case Report

Gastrointestinal (GI) metastasis of hepatocellular carcinoma is very rare. This is the first report of post-transplantation gastric metastasis. A 43-year-old man with a history of hepatitis B–related hepatocellular carcinoma (HCC) in the right anterior segment of the liver received an orthotopic liver transplant. Three months after the transplantation, pulmonary metastasis was found by chest computed tomography, and he received 1 course of gamma knife treatment. He complained of melena with anemia 17 months post liver transplantation. Abdominal CT scan showed new occupying lesions in the liver and a mass in the stomach and around the spleen with embolus in the splenic vein. Endoscopy revealed a large irregular cauliflower-like mass in fundus with ulceration and bleeding on the surface. He received symptomatic treatment, but died of cancer-related bleeding 4 months later. GI bleeding may due to gastric metastasis after liver transplantation.

An Case of Perforated Gastric Gastrointestinal Stromal Tumor (GIST) Complicated by Bacteremia and Liver Abscess

Introduction: GIST is one of the most common mesenchymal tumors in the gastrointestinal (GI) tract closely related to the interstitial cells of Cajal and generally express c-KIT (CD114), a tyrosine kinase receptor. The most common locations are the stomach (40%-60%), small intestine (30%-40%), anorectum (7%), colon, and esophagus, as well as in extra-GI locations such as mesentery, omentum, and peritoneum(< 5%). We report a case of metastatic and perforated gastric GIST complicated by streptococcus bacteremia and hepatic abscess. Body: A 73 year old male presented with generalized weakness. At admission, he was febrile to 100.7F with RUQ tenderness. Imaging revealed peritoneal implants, a mass like process with air inseparable from the wall of the stomach near the fundus measuring 10 cm and left lobe liver mass measuring 6.4 cm (Fig 1). The patient was started on broad spectrum antibiotics. Blood cultures grew streptococcus intermedius (viridans group). Liver mass biopsy specimen revealed fragments of necrotic tissue and liver parenchyma without viable tumor. Endoscopy revealed a ˜3 cm perforated ulcer which appeared to be communicating with fundal mass (Fig 2). Pathologic showed poorly differentiated tumor with epithelioid and stromal features, CD117 +, CD34 +, cytokeratin - and CD45- compatible with GIST. Patient was ruled out for endocarditis and received antibiotics for total of 6 weeks. The patient was managed non surgically and repeat imaging (Fig 3) at 3 months showed marked improvement on Imatinib.Figure 1Figure 2Figure 3Discussion: GIST are well circumscribed tumors which may exhibit an exophytic or an endophytic pattern compromising bowel lumen patency. Mucosal necrosis and ulceration can be seen in GISTs with an endophytic component. Approximately 10-30% of GISTs are malignant and have intra-abdominal spread. The propensity of a GIST to become malignant depends on the primary anatomic site. Regardless of size and malignancy status, GISTs have a tendency to disrupt GI mucosal integrity, forming a conduit through which colonizing bacteria gain access to the portal and systemic circulation, resulting in bacteremia and liver abscess. A hematogenous source should be suspected if streptococcus or staphylococcous species are identified. Cystic degeneration, necrosis, and focal hemorrhage have been described in larger GIST accounting for the observed central necrotic cavitation resulting in fistulous connections with nearby structures, including the gastric lumen. There are only few case reports of a perforated gastric GIST, despite a higher overall incidence of GISTs in stomach. In our case, we suspect that the infection seeded from the GIST and should be included in the differential diagnosis in patients with suspected abdominal neoplasm and bacteremia.

Isolated gastric varices: Splenic vein obstruction or portal hypertension?

The presence of isolated gastric varices without esophageal varices is thought to be highly suggestive of splenic vein obstruction. A review of our radiologic files revealed 14 patients with isolated gastric varices on barium studies performed during the past 10 years. Eight of the 14 patients had adequate clinical and/or radiologic follow-up to suggest the pathophysiology of the varices. Seven had evidence of portal hypertension, and the remaining patient had evidence of splenic vein obstruction. Six patients had signs of upper gastrointestinal (GI) bleeding. Double-contrast upper GI examinations revealed thickened, tortuous fundal folds in 6 patients and a lobulated fundal mass in 2. Thus, most patients with isolated gastric varices have portal hypertension rather than splenic vein obstruction as the underlying cause.

Esophageal achalasia probably due to gastric carcinoma.

A case of invasive gastric carcinoma mimicked idiopathic achalasia. Esophagoscopy, cineradiography, exfoliative cytology, manometry, and the methacholine (Mecholyl⌖) test were consistent with idiopathic achalasia. Only a high index of suspicion based on the short duration of symptoms and particularly the suggestion of a fundal mass in the upper gastrointestinal series led to the correct diagnosis. The demonstrated carcinomatous involvement of the esophageal ganglia probably produced the achalasia.