Submucosal Lesions Of Gastrointestinal Tract Research Articles

Role of Endoscopic Ultrasound in Diagnosis of Submucosal Lesions of Gastrointestinal Tract

The study aimed to understand the magnitude of submucosal lesions as part of the referral to the endoscopic ultrasound (EUS) unit in one year and know the percent of the different types and sites of submucosal lesions of GIT in Theodore Bilharz Research Institute as tertiary referral center draining Egyptian community. Within one year, all patients referred to the EUS unit at Theodore Bilharz Research Institute (TBRI) for assessment to assess the percent of submucosal lesions cases as part of the total referral and know the different types seen and their common sites as compared to the international literature. Patients diagnosed to have submucosal lesion will be subjected to; full clinical history, thorough physical examination, laboratory investigations, BUS for more characterization (site, size, location, echo pattern, etc.) and BUS-guided fine-needle aspiration (FNA) for histopathological examination. The work comprised 36 patients; 16 females and 20 males. Their ages ranged from 21 to 75 years. All patients had preliminary upper endoscopy or colonoscopy. According to the indication of upper preliminary endoscopy or colonoscopy, 12 (33.3%) were complaining of melena, 5 (13.8%) hematemesis, 1 (2.7%) bleeding per rectum, 7 (19.4%) upper abdominal pain, 2 (5.5%) dysphagia, finally, 8 (22.2%) vomiting. According to the site of the submucosal lesion, 24 (66.6%) were gastric, 6 (16.6%) esophageal, 4 (11.1%) duodenal, 1 gastro-esophageal (2.8%), and 1 (2.8%) rectal. 34 cases (94%) were covered by normal overlying mucosa while 2 cases (6%) had superficial ulcerations. It was concluded that EUS criteria, can be used without FNA and histopathologic examination to reduce the cost of differentiation between malignant and benign lesions. All homogenous lesions were benign. Lesion size of 4.5 cm is a cut off; > 4.5 cm were malignant whereas < 4.5 cm were benign. All submucosal lesions without areas of breakdown were benign. Those infiltrating all layers are malignant. EUS guided fine needle aspiration (FNA) and histopathological examination should be done for some submucosal masses to put a definite diagnosis. EUS with colored Doppler is necessary in differentiating cystic from vascular lesions.

Sa1192 EUS Guided Biopsy of Sub-Mucosal Lesions of Gastrointestinal Tract: PRO-Core Is the Needle of Choice

Endoscopic ultrasound (EUS) guided biopsy allows cytologic and/or histologic diagnosis of sub-mucosal lesions of the gastrointestinal tract (GIT). The diagnostic yield with fine needle aspiration (FNA), however, is often unsatisfactory (~30-40%). A newly developed Pro-Core needle (PCN) is able to obtain core tissue and may improve diagnostic yield. AIM: To compare the performance of two EUS guided biopsy needle systems, FNA versus PCN, in the evaluation of sub-mucosal lesions in the upper GIT. METHODS: Data related to patients referred for EUS and possible guided biopsy of sub-mucosal lesions in the upper GIT over 24 months were retrospectively reviewed. All specimens were prepared as cell-block for histo-cytological analysis. Measured outcomes were presence of diagnostic material, ability to perform immunohistochemistry (IHC), provision of a diagnosis, and complication. RESULTS: Of 84 patients who had EUS evaluation of an upper GIT sub-mucosal lesion, 30 patients did not have biopsy (lipoma=14, duplication cysts=6, vascular compression=1 and no abnormality=9). EUS-guided biopsy were performed in 54 patients, using 19-22G FNA (n=34) and 22G PCN (n=20) system, to clarify the tissue diagnosis of a hypo-echoic submucosal mass. There were no differences in age (61.1±2.6 vs. 59.2±5.3 yrs), gender (13M:17F vs. 3M:8F), site (22gastric : 8duodenal : 4esophageal vs. 17gastric : 1duodenal : 2esophageal) or size (2.1±0.1 vs. 2.1±0.3 cm) of biopsied lesion between the FNA and PCN groups, respectively. Biopsy with PCN obtained significantly more diagnostic material than FNA, leading to a substantially higher diagnostic yield (18/20 vs. 14/34; P ,0.001). Of the 17 suspected spindle cell tumours from the PCN group, IHC study (c-kit stain) were successful in all cases and provided tissue confirmation of 10 leiomyomas and 7 gastrointestinal stromal tumours (GIST). In contrast, only 7/14 patients with FNA needle had sufficient material for additional IHC study (P=0.008, vs. PCN), confirming GIST in only 3/12 of suspected spindle cell tumours. Neither group had abdominal pain or clinical significant bleeding after the biopsy. CONCLUSIONS: EUS guided biopsy with 22G PCN has substantially higher histocytological yield than that with FNA needles (90% vs. 41%) and without any complication. PCN, therefore, should be the needle of choice for tissue acquisition of sub-mucosal lesions in the GIT.

Sa1193 Quantitative Endoscopic Ultrasound Elastography (Q-EUS-E) in the Differential Diagnosis of Solid Pancreatic Masses: A Validation Study

Endoscopic ultrasound (EUS) guided biopsy allows cytologic and/or histologic diagnosis of sub-mucosal lesions of the gastrointestinal tract (GIT). The diagnostic yield with fine needle aspiration (FNA), however, is often unsatisfactory (~30-40%). A newly developed Pro-Core needle (PCN) is able to obtain core tissue and may improve diagnostic yield. AIM: To compare the performance of two EUS guided biopsy needle systems, FNA versus PCN, in the evaluation of sub-mucosal lesions in the upper GIT. METHODS: Data related to patients referred for EUS and possible guided biopsy of sub-mucosal lesions in the upper GIT over 24 months were retrospectively reviewed. All specimens were prepared as cell-block for histo-cytological analysis. Measured outcomes were presence of diagnostic material, ability to perform immunohistochemistry (IHC), provision of a diagnosis, and complication. RESULTS: Of 84 patients who had EUS evaluation of an upper GIT sub-mucosal lesion, 30 patients did not have biopsy (lipoma=14, duplication cysts=6, vascular compression=1 and no abnormality=9). EUS-guided biopsy were performed in 54 patients, using 19-22G FNA (n=34) and 22G PCN (n=20) system, to clarify the tissue diagnosis of a hypo-echoic submucosal mass. There were no differences in age (61.1±2.6 vs. 59.2±5.3 yrs), gender (13M:17F vs. 3M:8F), site (22gastric : 8duodenal : 4esophageal vs. 17gastric : 1duodenal : 2esophageal) or size (2.1±0.1 vs. 2.1±0.3 cm) of biopsied lesion between the FNA and PCN groups, respectively. Biopsy with PCN obtained significantly more diagnostic material than FNA, leading to a substantially higher diagnostic yield (18/20 vs. 14/34; P ,0.001). Of the 17 suspected spindle cell tumours from the PCN group, IHC study (c-kit stain) were successful in all cases and provided tissue confirmation of 10 leiomyomas and 7 gastrointestinal stromal tumours (GIST). In contrast, only 7/14 patients with FNA needle had sufficient material for additional IHC study (P=0.008, vs. PCN), confirming GIST in only 3/12 of suspected spindle cell tumours. Neither group had abdominal pain or clinical significant bleeding after the biopsy. CONCLUSIONS: EUS guided biopsy with 22G PCN has substantially higher histocytological yield than that with FNA needles (90% vs. 41%) and without any complication. PCN, therefore, should be the needle of choice for tissue acquisition of sub-mucosal lesions in the GIT.

Gastric Outlet Obstruction Due to Secreting Heterotopic Pancreas

Purpose: Introduction: Heterotopic pancreas (also termed as pancreatic rests) is a rare congenital anomaly of the gastrointestinal tract. Presence of heterotopic pancreatic tissue within the stomach is a rare cause of gastric outlet obstruction. We report an interesting case of gastric outlet obstruction as a complication of heterotopic pancreas presenting as a submucosal cyst in the gastric antrum diagnosed with endoscopic ultrasound (EUS). Case report: A 22 year old female with history of gastroesophageal reflux disease presented with 6 week history of progressively worsening nausea, emesis, heartburn and early satiety with weight loss. Esophagogastroduodenoscopy to the descending duodenum revealed a large, submucosal antral gastric lesion with partial gastric outlet obstruction. Abdominal computer tomography showed a 4 cm×2.7 cm low-density mass in the distal stomach. Subsequent EUS demonstrated a large 5 cm submucosal cystic lesion in the gastric antrum in layer three. EUS guided fine needle aspiration of the cyst revealed amorphous material. Biochemical studies of the fluid showed elevated amylase level with a value of 4,878 U/L and a CEA level of 96.6 ng/ml. Due to persistent symptoms, patient subsequently underwent distal gastrectomy with Roux-En-Y anastomosis. Final histological diagnosis showed gastric heterotopic pancreas. Discussion: Heterotopic pancreas is defined as the presence of pancreatic tissue outside normal pancreas that lacks anatomic or vascular continuity with main pancreas itself. Most common sites for heterotopic pancreas are stomach (25-38%), duodenum and jejunum. Complications include mechanical obstruction like gastric outlet obstruction in our patient, cyst formation, acute or chronic pancreatitis, bleeding due to ulceration and malignant transformation. Differential diagnosis of gastric submucosal lesions includes gastrointestinal stromal tumors, duplication cyst, lymphoma and gastric carcinoma. On endoscopy, heterotopic pancreas appears as a broad based submucosal lesion that may have umblication on the mucosal surface indicating the site of draining duct. EUS has proven to be very useful in diagnostic evaluation. Fine needle aspiration via EUS allows cytological evaluation of submucosal lesions which can usually confirm the diagnosis. Definite diagnosis of pancreatic heterotopia is by histology of the lesion. Symptomatic lesions are treated surgically. Submucosal lesions of gastrointestinal tract present a diagnostic challenge for gastroenterologists. Heterotopic pancreas, albeit a rare entity, should be considered in cystic lesions of gastric wall causing gastric outlet obstruction.

Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract.

Endoscopic ultrasound is widely used following endoscopy for evaluation of suspected submucosal lesions and may guide further management of patients. A total of 181 consecutive patients with suspected submucosal lesion in the upper gastrointestinal tract were diagnosed by endoscopic ultrasound between 1990-97. We evaluated: 1) the potential of endoscopic ultrasound criteria to predict histological type of submucosal lesions in 69 patients with available histology, 2) the ability of endoscopic ultrasound alone or with clinical presentation, to predict malignancy in 86 patients with available histology or follow-up of >12 months. Sensitivity and specificity for diagnosing 44 gastrointestinal stromal tumours were 95 and 72%, respectively, while 25 miscellaneous lesions were diagnosed correctly in only 56% by endoscopic ultrasound. Diagnosis of malignancy, using any two of three endoscopic ultrasound criteria (heterogeneous echotexture, size >3 cm, irregular margins) showed a sensitivity of 80% and specificity of 77%, giving accurate endoscopic ultrasound diagnosis in 16/20 malignant and 51/66 benign submucosal lesion. Heterogeneous echotexture, size >3 cm, and irregular margins showed a relative risk of 7.2, 5.4 and 4.6, respectively, for presence of malignancy. The presence of symptoms, potentially suggesting malignancy (dysphagia, gastrointestinal bleeding, pain and weight loss), had a relative risk of 4.2, however this did not increase the accuracy of diagnosing malignancy based on endoscopic ultrasound criteria alone. The accuracy of endoultrasound is high in diagnosing gastrointestinal stromal tumours, which show a significant potential of malignancy. Endoscopic ultrasound morphology appears to be helpful in selection of patients for surgical or conservative treatment. The accuracy of endoscopic ultrasound in differential diagnosis of non-gastrointestinal stromal tumour lesions is limited.