Gastric inflammatory fibroid polyps: endoscopic ultrasonographic analysis in comparison with the histology

Novel classification of gastric polyps: The good, the bad and the ugly

Gastric polyps (GPs) are increasingly common. On upper endoscopy, they should be examined with white light and occasionally chromoendoscopy, and their morphology classified according to the Paris classification. Most GPs have a typical endoscopic appearance and can be associated with diseases like Helicobacter pylori infection. Histological examination is necessary for an accurate diagnosis. While most polyps are non-neoplastic and do not require treatment, some carry a risk of malignancy or are already malignant. Therefore, understanding the diagnosis, classification, and management of GPs is crucial for patient prognostication. Our new classification categorizes GPs into "good", "bad", and "ugly" based on their likelihood of becoming malignant. We aim to provide descriptions of the endoscopic appearance, pathology, treatment, and follow-up for different GPs, as well as clinical management flowcharts.

Novel classification of gastric polyps: The good, the bad and the ugly

Gastric polyps (GPs) are increasingly common. On upper endoscopy, they should be examined with white light and occasionally chromoendoscopy, and their morphology classified according to the Paris classification. Most GPs have a typical endoscopic appearance and can be associated with diseases like Helicobacter pylori infection. Histological examination is necessary for an accurate diagnosis. While most polyps are non-neoplastic and do not require treatment, some carry a risk of malignancy or are already malignant. Therefore, understanding the diagnosis, classification, and management of GPs is crucial for patient prognostication. Our new classification categorizes GPs into "good", "bad", and "ugly" based on their likelihood of becoming malignant. We aim to provide descriptions of the endoscopic appearance, pathology, treatment, and follow-up for different GPs, as well as clinical management flowcharts.

Inflammatory polyp of the ileum causing small bowel intussusception: A case report

Adult intussusception is rare, and an underlying benign or malignant aetiology is often found. Inflammatory fibroid polyp, a benign neoplastic polyp that can arise anywhere in the gastrointestinal tract is a rare cause of intussusception of the small bowel. Clinical presentation differs depending on the location of the lesion in the gastrointestinal tract. Diagnosis may be confirmed on a computed tomography scan or ultrasound. Definite diagnosis is based on histopathology and immunocytochemistry. We present the case of a 58-year-old lady with an inflammatory fibroid polyp who presented with microcytic anaemia and chronic abdominal pain due to recurrent intussusception.

The role of endoscopic submucosal dissection in the management of gastric inflammatory fibroid polyps: a single-center experience

BACKGROUND AND AIM

gastric inflammatory fibroid polyps constitute only 0.1 % of all gastric polyps. They are usually amenable to resection by snare polypectomy. However, on rare occasions, these lesions may require resection by endoscopic submucosal dissection. This study aimed to evaluate the effectiveness and safety of endoscopic submucosal dissection in the management of gastric inflammatory fibroid polyps not amenable to resection with snare polypectomy.

METHODS

a retrospective observational study of all consecutive patients who underwent endoscopic submucosal dissection for gastric inflammatory fibroid polyps between January 2011 and December 2020 was performed.

RESULTS

there were nine cases of gastric inflammatory fibroid polyps resected by endoscopic submucosal dissection. Most patients were female (7/9) with a mean age of 62.2 years. All gastric inflammatory fibroid polyps were described as solitary antral subepithelial lesions with a mean diameter of 16.7 mm, which appeared well-circumscribed and homogeneous lesions located at muscularis mucosa and submucosa without deeper invasion on endoscopic ultrasound. All lesions were successfully resected by en bloc and complete resection with free margins obtained in 8/9 specimens. Adverse events were reported in 2/9 cases including one intra-procedural bleeding successfully controlled with hemostatic clips and one aspiration pneumonia that evolved favorably. Mean follow-up duration was 33.7 months and no delayed complications or cases of recurrence were reported.

CONCLUSIONS

endoscopic submucosal dissection appears safe and effective for the resection of gastric inflammatory fibroid polyps that present as large subepithelial lesions, if performed by experienced endoscopists after adequate characterization by endoscopic ultrasound, with high rates of technical success and low recurrence rates.

Rare Finding of Inflammatory Fibroid Polyp of the Duodenum: A Complete Diagnostic and Pathological Workup

Inflammatory fibroid polyps (IFP) are solitary benign tumors rarely found in the gastrointestinal (GI) tract. Additionally, duodenal polyps are diagnosed incidentally. We present a case of a 51-year-old female admitted to the department with an initial diagnosis of duodenal polyp on gastroscopy, CT, and positron-emission tomography (PET). COVID-19 pandemics was the reason for delayed treatment which allowed the lesion to progress and almost double its size in an eight-month period. We performed conventional duodenotomy and excision of the polyp. Diseases like gastrointestinal stromal tumor (GIST), inflammatory myofibroblastic tumor, and inflammatory polyp of Crohn's disease must be considered in the differential diagnosis of IFP because they could be observed in the same location.

Inflammatory Fibroid Polyp of the Gastrointestinal Tract: A Systematic Review for a Benign Tumor

BACKGROUND/AIM

Inflammatory fibroid polyp (IFP) is a rare, usually solitary and intraluminal polypoid benign tumor that can affect any part of the gastrointestinal (GI) tract, although in the majority of cases it affects the stomach. This lesion is characterized by proliferation of highly vascular fibrous tissue and infiltration by a variable number of different inflammatory cells. Its etiology is unknown. Our aim was to describe all the reported data concerning IFP.

MATERIALS AND METHODS

An extensive search of the PubMed Index was performed for publications with titles or abstracts containing the terms: "inflammatory fibroid polyp" with/without "Vanek". Results were filtered for publications in English and concerning only humans. One hundred and twenty-four publications were finally included in this review.

RESULTS

IFP has a female predominance. It affects patients in their 5th decade of life, although there are cases of patients from 4 to 84 years of age. IFP usually affects the stomach and more specifically the gastric antrum but can be detected throughout the GI tract. A significant number of cases remain asymptomatic but the most frequent presentations of IFP are abdominal pain, acute abdomen and GI bleeding. Most cases are treated by endoscopic resection of the lesion. No recurrence nor IFP-specific complications have been reported. Histopathology of IFP varies.

CONCLUSION

It is relatively safe to conclude that both the etiology and the timing of diagnosis might change the histopathology, immunohistological staining and tissue structure of IFP. Suggested theories should be taken into consideration with caution as the etiology and pathophysiological mechanisms of IFP are unknown.

Gastric Inflammatory Fibroid Polyp: A Rare Cause of Occult Upper Gastrointestinal Bleeding

Inflammatory fibroid polyps (IFPs) are rare mesenchymal lesions that can arise throughout the gastrointestinal tract. These tumors represent less than 0.1% of all gastric polypoid lesions and are frequently found incidentally on endoscopic evaluation. While presenting symptoms depend on the location of the tumor, gastric polyps commonly present with epigastric pain and early satiety. We hereby delineate the case of a middle-aged female who presented with chronic iron deficiency anemia and a positive fecal occult blood test. She underwent an upper endoscopy, which revealed an actively oozing umbilicated lesion in the gastric antrum. Endoscopic ultrasound divulged the submucosal origin of the lesion. It was subsequently excised using endoscopic mucosal resection. Pathologic examination of the resected specimen confirmed the diagnosis of gastric IFP. Furthermore, we conducted a systematic literature search of the MEDLINE database centered on gastric IFPs from January 2000 till March 2020. The data on patient demographics, clinical features, endoscopic findings, lesion site and size, and treatment approaches were collected and analyzed. This article illustrates the overarching need for clinicians to be vigilant of gastric IFPs presenting with initial clinical symptoms suggestive of occult upper gastrointestinal bleeding. Prompt diagnosis and management of gastric IFPs carry paramount importance to combat chronic unexplained iron deficiency anemia following occult bleeding in such patients. A concoction of endoscopy, biopsy, and immunohistochemical examination can be employed toward their prompt detection. Although gastric IFPs have conventionally been treated with surgery, endoscopic resection is now emerging as a safe and efficient therapeutic modality.

Inflammatory Fibroid Polyp: An Unusual Cause of Abdominal Pain in the Upper Gastrointestinal Tract a Case Report

Inflammatory fibroid polyps (IFPs) tend to occur in the gastrointestinal tract, and they are rare and benign neoplasms. In general, IFPs often come from epithelial tissue. The gastric antrum is the most common location. Endoscopic ultrasound (EUS) often shows a predominantly hypoechoic mass with well-defined borders originating from the submucosal area. Here, we report the case of a 46-year-old woman with abdominal pain who underwent computed tomography (CT), endoscopic ultrasound and endoscopic submucosal dissection (ESD) of resected specimens; the diagnosis was ultimately an inflammatory fibroid polyp. She is currently in clinical remission.

A case of inflammatory fibroid polyp of the stomach with an "erect penis like appearance" successfully removed by endoscopic submucosal dissection

A 37-year-old woman was diagnosed by esophagogastroduodenoscopy (EGD) as having a 15-mm subepithelial lesion (SEL) in the gastric body. For 2 years, she experienced epigastric pain and anemia; she then underwent emergency EGD, which revealed a significant morphological change of the lesion. The SEL had a disintegrated tip and its submucosal portion was substantially exposed out of the mucosa, showing an "erect penis like appearance". Based on the pathological findings of biopsied samples from the exposed portion and the endoscopic features, an inflammatory fibroid polyp (IFP) was suspected. This lesion was considered responsible for the anemia and was removed by endoscopic submucosal dissection (ESD). The pathological findings confirmed the lesion to be IFP. This report presents a case of gastric IFP that showed a marked morphological change and unique endoscopic features and was successfully removed by ESD.

Gastric inflammatory fibroid polyp tumor with acute intestinal obstruction-Vanek's tumor can mimick a giant gastrointestinal stromal tumor or a gastric lymphoma

An inflammatory fibroid polyp (IFP) is a solitary rare benign neoplasm of the gastrointestinal tract, frequently located in the gastric antrum. IFPs account for about 0.1% of all gastric polyps. We report a case of a giant gastric inflammatory polyp of 2.5 cm × 7 cm that determines a gastric outlet obstruction called "ball valve syndrome" mimicking a gastrointestinal stromal tumor (GIST) and a gastric lymphoma, with an intestinal obstruction of high origin. Therefore, due to acute presentation we have decided to submit the patient to a subtotal gastrectomy. The patient was discharged two weeks later, asymptomatic. At 14 months of follow-up, patient is disease free at abdominal CT and OGDS. Depending on their size and location, IFPs can be associated with unspecific symptoms. Giant IFPs of the gastric antrum or the duodenum can determine an intermittent gastric outlet obstruction called "ball valve syndrome". Endoscopic biopsies are unhelpful and right diagnosis can be reached only with resection. In fact, only about 10% of the gastric lesions are diagnosed correctly prior to resection. Surgical treatment with complete resection with safe margins is curative. Giant IFPs are rare benign lesions whose atypical presentation can mimic GISTs, lymphomas or carcinomas. Clinical and radiological findings may not clarify the right diagnosis until histopathological evaluation aided with immunohistochemical analysis. The resection of IFPs with negative margins is curative with a good clinical outcome. In acute presentation, like in our case, surgery is the mainstay of treatment.

Endoscopic Ultrasonography in the Diagnosis of Gastric Subepithelial Lesions

Subepithelial lesions occasionally found in the stomach of patients undergoing endoscopy may be either benign lesions or tumors with malignant potential. They may also appear due to extrinsic compression. Discrimination of gastric subepithelial lesions begins with meticulous endoscopic examination for size, shape, color, mobility, consistency, and appearance of the overlying mucosa. Accurate diagnosis can be achieved with endoscopic ultrasonography, which provides useful information on the exact size, layer-of-origin, and characteristic morphologic features to support a definitive diagnosis. Endoscopic ultrasonography also aids in the prediction of malignant potential, especially in gastrointestinal stromal tumors. Features of subepithelial lesions identified on endoscopic ultrasonography can be used to determine whether further diagnostic procedures such as endoscopic resection, fine needle aspiration, or core biopsy are required. Endoscopic ultrasonography is a valuable tool for diagnosis and clinical decision making during follow-up of gastric subepithelial lesions.

A Large Gastric Inflammatory Fibroid Polyp

Inflammatory fibroid polyp (IFP) is an unusual benign gastrointestinal subepithelial tumor (SET). The endosonographic (EUS) features of IFPs were sporadically reported on imaging tips or small case series study. However, the differential diagnosis and optimal treatment of gastric IFP is still challenging. We report an unusual case of a large erosioned and prolapsing gastric submucosal lesion, presenting primarily with obstructive symptoms ("ball valve syndrome") and anemia. On EUS examination, a 50 mm SET in the distal antrum was seen, with hypoechoic but heterogeneous echo-pattern, located in the second and third sonographic layers of the gastric wall (deep mucosal and submucosal). The fourth (muscle) layer was intact; no peri-lesional adenopathies were identified. A decision was made to proceed to endoscopic treatment because of the mentioned symptoms. Histopathologic evaluation of the resected specimen with immunohistochemical staining was consistent with the diagnosis of IFP. IFP rarely reach these large dimensions or cause symptoms. Despite its benign etiology, endoscopic resection was important in both establishing a histologic diagnosis and treatment. EUS was crucial in the differential diagnosis. The literature concerning IFP is also reviewed.

Endoscopic diagnosis and treatment of inflammatory fibroid polyps

AIM: To investigate the clinical manifestations, endoscopic and ultrasonographic features, and endoscopic therapy of gastric inflammatory fibroid polyps (IFPs).

METHODS: A total of 13 patients with IFPs treated at our center were collected between January 2007 January and April 2014. The clinical data for these patients were reviewed. All patients underwent digestive endoscopy, and 5 patients whose lesions were located at the antrum underwent endoscopic ultrasonography before therapy. Therapeutic methods were selected based on endoscopic morphology of the lesion.

RESULTS: IFPs had a modest female predominance (8 women and 5 men), with the majority of patients (11) being more than 50 years. Involved sites included the stomach (10), ileum (2), and colon (1). The tumors ranged in size from 6-60 mm (mean, 21.62 mm). Endoscopic features of the 13 lesions were submucosal tumors (7), polyps (3) and neoplasms (3). All lesions were located in the second (2) or third (3) sonographic layer of the antrum without involvement of the fourth layer. Endoscopic ultrasonographic features were hypoechoic/homogeneous echo pattern and unclear boundary. Four patients underwent endoscopic mucosal resection (EMR), 6 underwent endoscopic submucosal dissection (ESD) and 3 partial gastrointestinalresection. All were confirmed histologically as IFPs.

CONCLUSION: IFPs can occur throughout the gastrointestinal tract, commonly in the antrum. Understanding the characteristic digestive endoscopy and EUS features of IFP scan be helpful to IFP diagnosis. Treatmentby EMR or ESD iseffective and safe.

Evaluation of clinico-pathological features and Helicobacter pylori infection in gastric inflammatory fibroid polyps

Inflammatory fibroid polyps are rare mesenchymal lesions. The frequency of Helicobacter pylori infection in the gastric mucosa overlying inflammatory fibroid polyps and its relation with the histologic features of the polyps are undetermined. The clinico-pathological features of inflammatory fibroid polyps, the frequency of Helicobacter pylori infection in the overlying gastric mucosa, and its putative impact on the phenotype of the polyps were evaluated. Gastric inflammatory fibroid polyps diagnosed in our Hospital from 1998 to 2012 were reviewed and the histological. The histological sections were stained with hematoxylin and eosin and modified Giemsa for the evaluation of Helicobacter pylori infection. Inconclusive cases were further analyzed by immunohistochemistry with anti-Helicobacter pylori antibody. Diagnosis was confirmed in 54 polyps, 85 % developed in females, mean age 63 ± 11 years. Most polyps were sessile (74 %), with a mean size of 15 ± 12 mm, 96 % were located in the antrum and 85 % were removed by snare polypectomy. Helicobacter pylori infection was identified in 48 % of the polyps. Most inflammatory fibroid polyps developed in the submucosa, and mucosal extension was observed in 96 % of the cases. Chronic gastritis was observed in all cases (63 % with activity, 31 % with intestinal metaplasia, and 61 % with foveolar hyperplasia). Erosion and ulceration of the overlying gastric mucosa was observed in 48 % and 11 % of the polyps, respectively. Onion skin features were present in 52 % of the polyps and were more frequently observed in cases without evidence of Helicobacter pylori infection. Background changes in gastric mucosa were not distinctive according to Helicobacter pylori infection. Chronic atrophic gastritis with intestinal metaplasia was associated with the presence of perivascular onion skin lesions. To our knowledge, this is the second largest series of gastric inflammatory fibroid polyps. Helicobacter pylori infection was identified in about half of the cases and was associated with a lower frequency of onion skin features in the polyps.

Giant Inflammatory Fibroid Polyp of the Descending Colon Treated with Endoscopic Resection

Inflammatory fibroid polyps (IFPs) of the colon are very rare, reactive, non-neoplastic polyps that may grow to large sizes but do not carry any risk of malignancy. Because of their size, IFPs are usually treated with surgery; however, size alone should not be an indication for surgery. Depending on the location and morphology of the polyp, endoscopic resection should be considered. We here describe a case of a giant IFP that was successfully removed with endoscopy without complication or recurrence.

Clinicopathologic features of inflammatory fibroid polyp of the esophagus

AIM: To explore the clinical and pathological features of inflammatory fibroid polyp (IFP) of the esophagus and to discuss its diagnosis, differential diagnosis, treatment and prognosis.

METHODS: A case of IFP of the esophagus was investigated by light microscopy and immunohistochemistry. A literature review was then performed to summarize the clinical and pathological features of the disease.

RESULTS: A 71-year-old man presented with epigastric/retrosternal pain and dysphagia for 3 months. Endoscopy revealed a hemispheric lesion, 2.5 cm in size, in the esophageal mucosa about 35 cm from incisors. On EUS, the lesion (13.2 mm x 11 mm) was hypoechogenic and inhomogeneous, and was located under the mucosa of the esophagus, with a clear boundary. Surgical resection of the esophageal mass was performed, and the final pathologic diagnosis was IFP of the esophagus.

CONCLUSION: IFP of the esophagus is an extremely rare mesenchymal tumor with benign behavior and good prognosis. A correct preoperative diagnosis is difficult and relies on postoperative pathological examination. Surgical excision is the preferred treatment for IFP.

Diagnosis of subepithelial tumors in the upper gastrointestinal tract by endoscopic ultrasonography

Endoscopic ultrasonography (EUS) is the most accurate procedure for detecting and diagnosing subepithelial tumors, due to its higher sensitivity and specificity than other imaging modalities. EUS can characterize lesions by providing information on echogenic origin, size, borders, homogeneity, and the presence of echogenic or anechoic foci. Linear echoendoscopes, and recently also electronic radial echoendoscopes, can be used with color Doppler or power Doppler to assess the vascular signals from subepithelial masses, and thus permit the differentiation of vascular structures from cysts, as well as the assessment of the tumor blood supply. However, the diagnostic accuracy of EUS imaging alone has been shown to be low in subepithelial lesions with 3rd and 4th layers. It is also difficult to differentiate exactly between benign and malignant tumors and to gain an accurate picture of histology using EUS. On the other hands, EUS guided fine needle aspiration (EUS-FNA) can provide samples for cytologic or histologic analysis. Hypoechoic lesions of the 3rd and the 4th EUS layers, more than in 1 cm diameter are recommended, and histologic confirmation using endoscopic submucosal resection or EUS-FNA should be obtained when possible. Therefore, EUS-FNA plays an important role in the clinical management of subepithelial tumors. Furthermore improvements in endoscopic technology are expected to be more useful modalities in differential diagnosis and discrimination between benign and malignant subepithelial tumors.

Ultrasonographic appearance of canine gastric polyps

Benign gastric polyps are uncommon in dogs and most are discovered incidentally. Polyps protruding into the pyloric antrum can cause gastric outflow obstruction. Clinical and ultrasonographic findings in seven dogs with histologically confirmed benign mucosal gastric polyps were reviewed. Sonographic findings such as shape, size, echogenicity, location, evidence of gastric wall thickening, wall layering, and size of regional lymph nodes were recorded. Five sessile and two pedunculated masses of different sizes (range 7-60 mm) and echogenicities were found. They primarily arose from the mucosal layer and protruded into the gastric lumen. Only one dog had a large inhomogeneous mass with a poorly visualized gastric wall layering. The polyps were all single, and were located in the pyloric antrum in six out of seven dogs. Although the ultrasonographic appearance allowed a presumptive diagnosis of mucosal gastric polyp, the final diagnosis was determined from histopathologic examination.

Case of an inflammatory fibroid polyp of the cecum

An inflammatory fibroid polyp (IFP) is a rare benign lesion, originating in the submucosa of the gastrointestinal tract. It is histopathologically characterized by distinctively arranged fibrous connective tissue and blood vessels with inflammatory cell infiltration. It typically arises in the stomach and small intestine but also arises infrequently in the colon. This report describes a case of IFP of the cecum. A 63-year-old woman presented with persistent bloody stool for more than 1 month. Colonoscopy revealed a polypoid lesion, measuring 2.5 cm in diameter and 4 cm in length, with a thick pedicle in the cecum. Histopathological examination of the biopsy specimen showed hyperplastic changes of the mucosa. The lesion was diagnosed to be a submucosal tumor. We concluded that endoscopic mucosal resection would be difficult because the polyp showed signs of infiltration into the submucosa. Furthermore, the possibility of malignancy could not be ruled out. Laparoscopy-assisted ileocecal resection with lymphnode dissection was performed after the patient's informed consent was obtained. The lesion was finally diagnosed to be IFP on the basis of histopathological examination of the resected specimen. Immunohistochemical staining of the spindle-shaped cells, which were present around the small vessels in the stroma of the tumor, showed that the tissue expressed vimentin but not alpha-smooth muscle actin, desmin, S-100, c-kit or CD 34. IFP is difficult to diagnose without the recognition of its clinical and pathological characteristics. It is also important to determinate the depth of the lesion before selecting the therapeutic method.

A rare cause of anaemia (2008: 3b)

Inflammatory fibroid polyp is a rare benign lesion of the gastrointestinal tract, frequently seen in the antrum of the stomach. We report a case of a 50-year-old man with a large inflammatory fibroid polyp and located in the cardia of the stomach. Corresponding computed tomography, endoscopy and histology findings are discussed.

[Gastric polyps]

Gastric polyps exist in a wide variety of types, most often benign. Endoscopic discovery of gastric polyps necessitates biopsies - not only of the lesion but also of the antral and fundic mucosa to determine the therapeutic strategy and subsequent surveillance. Fundic gland polyps are the most frequent type; they are asymptomatic with no malignant potential. They require neither treatment nor surveillance. Hyperplastic polyps, adenomas and tumors must be totally resected. Biopsies alone are insufficient to assess the extent of malignancy of adenomas and of hyperplastic polyps more than 5 mm in diameter. These polyps are associated with an elevated frequency of precancerous alterations of the gastric mucosa and consequently by an elevated risk of synchronous or metachronous cancer. Eradication of Helicobacter pylorus may reduce the risk of metachronous gastric cancer and recurrence after resection. Carcinoid tumors of the fundus most often occur in patients with hypergastrinemia during atrophic gastritis of autoimmune origin; they are not serious. The advantages and procedures for endoscopic surveillance of patients with a precancerous condition of the gastric mucosa have not yet been clearly established in populations with a low incidence of cancer.

Yield of tissue sampling for subepithelial lesions evaluated by EUS: a comparison between forceps biopsies and endoscopic submucosal resection

BACKGROUND

In most circumstances, subepithelial tumors lack distinct endoscopic and ultrasonographic features. Consequently, definitive diagnosis usually requires tissue acquisition and pathologic confirmation. Establishing a tissue diagnosis is difficult because the yield of forceps biopsies is low. However, prospective data evaluating tissue sampling techniques for subepithelial lesions are currently lacking.

OBJECTIVE

Our purpose was to prospectively determine the diagnostic yield of endoscopic submucosal-mucosal resection (ESMR) compared with forceps biopsy for lesions limited to the submucosa (third endosonographic layer) of the GI tract.

DESIGN

A prospective head-to-head comparison was performed.

SETTING

The study was performed in a tertiary care hospital.

PATIENTS

Study patients were 23 adults with subepithelial lesions limited to the submucosa.

INTERVENTION

All submucosal lesions underwent forceps biopsy followed by endoscopic submucosal resection. Biopsy specimens were obtained with large-capacity "jumbo" forceps. A total of 4 double passes (8 biopsy specimens) were collected from each lesion with use of the bite-on-bite technique. Endoscopic resection was then performed with an electrosurgical snare or cap-fitted endoscopic mucosal resection device.

MAIN OUTCOME MEASUREMENT

The main outcome measurement was the diagnostic yield of biopsy forceps compared with endoscopic submucosal resection.

RESULTS

Twenty-three patients with lesions limited to the submucosa were identified by endoscopic ultrasonography. All lesions underwent forceps biopsy followed by ESMR. The diagnostic yield of the jumbo forceps biopsy was 4 of 23 (17%), whereas the diagnostic yield of ESMR was 20 of 23 (87%) (P = .0001, McNemar test).

CONCLUSION

In the evaluation of subepithelial lesions limited to the submucosa, ESMR has a significantly higher diagnostic yield than jumbo forceps biopsy with use of the bite-on-bite technique.

American Gastroenterological Association Institute technical review on the management of gastric subepithelial masses

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on January 19, 2006, and by the AGA Institute Governing Board on April 20, 2006.

Submucosal lesions

Most of the submucosal lesions encountered on endoscopy are benign; however, the fact that some of them may be malignant considerably influences the attitude toward the whole group. This article reviews the current status of endosonography in the management of submucosal lesions and focuses on determining the risk of malignancy. The predictive value of various endoscopic ultrasonography (EUS) features and their combinations and the capabilities and limitations of EUS-guided fine needle biopsy are discussed. Other issues addressed include differentiation between extraluminal compressions and true submucosal lesions, EUS-assisted endoscopic removal of submucosal lesions, and the potential role of catheter-based endosonography in the setting of submucosal lesions. Problems related to the surveillance of patients with submucosal lesions who are not candidates for surgical treatment are outlined. An overview of the recent changes in the pathologic classification of gastrointestinal mesenchymal tumors and their impact on the role of EUS in the management of submucosal lesions is given.

Computed tomographic image of an inflammatory fibroid polyp of the stomach

Inflammatory fibroid polyp (IFP) is a rare benign lesion of the gastrointestinal tract. We report a case of IFP and its computed tomographic (CT) findings. On CT, the tumor protruded into the stomach and was covered with mucosa that was well enhanced. The inside of the tumor was irregularly enhanced, reflecting the typical histological findings of IFPs. Not only endoscopy and endoscopic ultrasonography (EUS) but also CT findings may be useful to diagnose IFP before polypectomy.

Inflammatory fibroid polyp of the esophagus

The case of a 76-year-old woman with a submucosal tumor of the esophagus, whose principal symptoms were dysphagia and epigastric/retrosternal pain, is reported here. Endoscopy, barium swallow and a CAT scan all pointed to extramucosal localization. The lesion was located in the lower esophagus lying on the stomach fundus. An ulcer in the region of the cardia complicated the tumor. Two sets of conventional biopsies failed to detect malignancy, only inflammation and intestinal metaplasia were seen in the specimens of the mucosa surrounding the ulcer. The endoscopic ultrasonographic findings were an indistinct margin, hypoechogenicity, homogeneous appearance and location within the second and third echographic layer. The surgical resection of the tumor was complemented by an anterior partial fundoplication. The histologic study revealed an inflammatory fibroid polyp, which is a rare, benign, non-capsulated submucosal lesion composed mainly of loose connective tissue and vessels, with an eosinophilic inflammatory component. This lesion is seldom found in the esophagus.

Gastric aberrant pancreas: EUS analysis in comparison with the histology

BACKGROUND

Histologic diagnosis of aberrant pancreas is usually difficult when tissue samples are obtained with a standard biopsy forceps. The aim of this study was to describe the endosonographic (EUS) features of gastric aberrant pancreas.

METHODS

EUS was performed in 10 patients with aberrant pancreas before resection. EUS features of the lesions were analyzed and compared with resected specimens retrospectively.

RESULTS

EUS in 5 lesions (50%) demonstrated the ectopic pancreatic tissue as located in the third and fourth sonographic layers (submucosa and muscularis propria) and in the third layer (submucosa) in the other 5 lesions. The margin appeared for the most part indistinct (80%) because of the lobular structure of the acinous tissue. The internal echo pattern in all cases was heterogeneous, mainly a hypoechoic image (acinous tissue) accompanied by scattered small hyperechoic areas (adipose tissue). An anechoic area (duct dilatation) (80%) and fourth-layer thickening (muscular hypertrophy) (80%) were commonly visualized.

CONCLUSION

Gastric aberrant pancreas has characteristic EUS features that correlate with specific histologic components and is variable with regard to sonographic layer of origin.

Gastric polypoid lesions--illustrative cases and literature review

Currently, upper gastrointestinal endoscopies are frequently performed for patients with various gastrointestinal symptoms. From time to time, lumps and bumps in the stomach are encountered on endoscopy. Four cases of gastric polypoid lesions are presented. The classification, differentiation, and management approach to these lesions are discussed. Although there is consensus that all gastric adenomatous polyps should be removed, as should gastric hyperplastic polyps that are symptomatic and/or bear dysplastic foci on forceps biopsy, controversy still exists over the management of asymptomatic gastric hyperplastic polyps that do not bear any dysplastic focus on forceps biopsies. Endoscopic ultrasonography (EUS) has a promising role in the evaluation of gastric submucosal polypoid lesions.