Three other types of duodenal polyps: Mucosal cysts,focal foveolar hyperplasia,and hyperplastic polyp originating from islands of gastric mucosa

Summary Seven cases are reported that initially presented on endoscopic examination as duodenal polyps originating from islands of gastric mucosa within the duodenal bulb. Microscopic examination revealed mucosal cysts (MC), focal foveolar hyperplasia (FFH), and hyperplastic polyp (HPP). These lesions must be added to the list of neoplastic and tumorlike lesions of the duodenum that may endoscopically present as polyps.     

LARGE HYPERPLASTIC POLYP DEVELOPING AFTER ENDOSCOPIC MUCOSAL RESECTION OF GASTRIC ADENOMA IN A PATIENT RECEIVING IMMUNOSUPPRESSIVE THERAPY

A 59‐year‐old man underwent endoscopic mucosal resection (EMR) for gastric adenoma. He had suffered from end‐stage renal disease for several years and had received renal transplantation some 5 months before EMR. Subsequently, he took immunosuppressive agents. Follow‐up gastrofiberscopy 6 months after EMR showed a sessile polyp at the resection site twice as large as the original adenoma; biopsy specimens revealed a hyperplastic nature. At the time of writing, this hyperplastic polyp has neither increased in size nor developed adenomatous or carcinomatous changes by histological examinations over the past 5 years. Therefore, this is a case of hyperplastic polyp occurring at the gastric adenoma resection site, and suggests the possible effect of immunosuppressive therapy on the post‐EMR healing process and hyperplastic polyp development.     

SUCCESSFUL ENDOSCOPIC SUBMUCOSAL DISSECTION FOR MUCOSAL CANCER OF THE DUODENUM

We report a case of mucosal duodenal cancer in a 62‐year‐old woman, which was successfully removed en bloc by endoscopic submucosal dissection (ESD). The patient underwent an upper gastrointestinal endoscopy at our hospital, which revealed an elevated flat mucosal lesion (type IIa) measuring 10 mm in diameter in the second portion of the duodenum. Histopathological examination of a biopsy specimen revealed features suggestive of a tubulovillous adenoma with severe atypia. As the findings suggested that the lesion had an adenocarcinoma component but was confined to the mucosal layer, we decided to carry out ESD and successfully removed the tumor in one piece. The resected tumor was 20 × 15 mm in size. Histopathological examination revealed that the lesion was a well‐differentiated mucosal adenocarcinoma with no lymphovascular invasion. Mucosal duodenal cancer is extremely rare, and ESD of a lesion in the duodenum requires a high level of skill. To the best of our knowledge, this case is the first report of successful ESD carried out in a case of mucosal duodenal cancer.     

Inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum

Benign neoplasia of the duodenum are very rare.Moreover, duodenal tubulovillous adenomas are more uncommon lesions. The microscopic structure of tubulovillous adenoma has frond-like projection of mucosa with branching papillary structure and generally upward growth into the lumen. We describe a 72-year-old man who showed aduodenal tubulovillous adenoma with unusual inverted cystic growth pattern.Interestingly, this tubulovillous adenomatous lesion was interrupted by gastric metaplasia in the deep portion of the cyst and was closely surrounded by Brunner's glands. Although histogenesis of gastric metaplasia of duodenum is not fully understood, Brunner's glands has been suggested as a precursor for gastric metaplasia.Therefore, these findings argued that this adenoma arises from Brunner's glands through gastric metaplasia.This is the first case of inverted cystic tubulovillous adenoma involving Brunner's glands of duodenum with gastric metaplasia.     

Brunner’s gland adenoma is a rare cause of upper gastrointestinal bleeding: A case report and literature review

Brunner’s gland adenoma is a rare benign tumour that arises from Brunner’s glands in the duodenum. Lesions are usually incidentally discovered during oesophagogastroduodenoscopy. However, in some cases, they may present clinically with vague abdominal symptoms or bleeding. We present the case of a 54-year-old male who complained of progressive fatigue and intermittent melena for 3 months. Clinical examination findings were unremarkable. Routine blood tests showed microcytic hypochromic anaemia. Oesophagogastroduodenoscopy showed normal oesophageal and gastric mucosa as well as a pedunculated polyp on the anterior wall of the duodenal bulb. Endoscopic ultrasound (EUS) revealed a duodenal hyperechoic mass arising from the submucosal layer of the anterior wall of the duodenal bulb with central cystic degeneration. Both endoscopic- and EUS-guided biopsies were non-diagnostic. Endoscopic mucosal resection was performed after the patient provided consent. Histopathological examination revealed hyperplastic mucosal lobules containing Brunner’s glands and smooth muscle cells; malignant cells or Helicobacter pylori infection were not evident. Brunner’s gland adenoma is a rare lesion of the duodenum and should be considered in the differential diagnosis of upper gastrointestinal bleeding. EUS is helpful in the diagnosis and detection of the layer of origin. However, the final diagnosis is usually made after lesion removal.     

Heterotopic Gastric Mucosa: A Case Report

A case of heterotopic gastric mucosa in discrete nodules of the duodenum is presented. Its radiographic and endoscopic appearance is described. The light and electron microscopic features are analyzed. Ultrastructural examination of its organization, cellular and subcellular components revealed similarities to normal fundic gastric mucosa. The histological and clinical differences between heterotopic gastric mucosa and duodenal metaplastic change are discussed.     

Xanthelasmas of the upper gastrointestinal tract

Background Gastric xanthelasma is a benign and uncommon lesion with a variably reported frequency, while esophageal and duodenal xanthelasmas are quite rare.Methods Seventeen patients who had the diagnosis of xanthelasma in the upper gastrointestinal tract were analyzed retrospectively with respect to their demographic, clinical, endoscopic, and histopathologic features. All lesions suspected as xanthelasma were totally removed by either hot biopsy forceps or a snare with the technique of endoscopic mucosal resection.Results The incidence of upper gastrointestinal xanthelasmas in 7320 patients who had upper gastro-intestinal endoscopy was 0.23%. There were 9 (53%) men and 8 (47%) women, with a median age of 50 years (range, 24–80 years). The most common location of xanthelasmas was the stomach (76%), followed by the esophagus (12%) and duodenum (12%). All lesions were observed as yellow-white colored plaques at endoscopy. Multiple xanthelasmas were detected in 4 patients (24%); in the duodenum in 2, esophagus in 1, and stomach in 1. One patient had xanthelasma within a gastric hyperplastic polyp. The size of the lesion was less than 5mm in diameter in 14 (82%) patients and between 5 and 10mm in diameter in 3 (18%). Thirteen (76%) patients had moderate to severe atrophic gastritis, while the remainder had normal gastric mucosa.Conclusions Xanthelasmas of the upper gastrointestinal tract were mostly located in the stomach in the present series, which includes the second and third reported cases of duodenal xanthelasma, the second case of xanthelasma developed within a hyperplastic gastric polyp, and the fourth and the fifth cases of esophageal xanthelasma.     

A case of giant heterotopic Brunner's gland adenoma prolapsing into the duodenum

A 81-year-old woman admitted with general fatigue was found to have a giant polyp in the gastric antrum by endoscopy. The polyp prolapsed into the duodenum through the pylorus. Angiographic examination of the abdomen revealed the polyp to be about 90×35 mm in size. Laparotomy was performed. It was finally diagnosed as heterotopic Brunner's gland adenoma which had a stalk on the antrum of the stomach. Heterotopic Brunner's gland adenoma is rare. Only 3 cases including the present case have been reported in Japan.     

Heterotopic gastric mucosa in the gallbladder

We report on a case of heterotopic gastric mucosa in the body of the gallbladder. A 39-year-old man, who was asymptomatic, visited our hospital because of a polypoid lesion in the gallbladder, discovered during a routine health screening. Ultrasonography (US) revealed a broad-based polypoid lesion 1.7 cm in diameter in the body of the gallbladder, which was free of gallstones. The gallbladder mass was faintly enhanced by helical computed tomography. Laparoscopic cholecystectomy was performed because of the possibility of malignancy. The specimen revealed a 1.7 × 1.3 cm polypoid lesion with deep delle in the body, with no gallstones in the gallbladder. Intraoperative frozen examination yielded a diagnosis of hyperplastic polyp of the gallbladder. Histologically, the polypoid lesion consisted of gastric fundic glands located in the whole wall of the gallbladder. The surrounding mucosa consisted of almost normal epithelium without any metaplastic changes. Postoperative technetium 99m-pertechnetate scintigraphy demonstrated no evidence of gastric heterotopia elsewhere in the body. We also review 18 other reports of heterotopic gastric mucosa in the gallbladder in the Japanese medical literature. Received: June 23, 1999 / Accepted: October 22, 1999     

Duodenal Adenoma Removed by Endoscopic Polypectomy

Abstract: We report two duodenal adenoma cases treated by endoscopic polypectomy. Case 1, a 59-year-old male, visited our hospital for further examination of a duodenal polyp found elsewhere. X-ray examination revealed a semi-pedunculated polyp with an irregular surface in the second portion of the posterior wall of the duodenum. Case 2, a 68-year-old male, was admitted to our hospital for endoscopic polypectomy of a duodenal polyp. Upper GI series demonstrated a semi-pedunculated round polyp with a shallow central depression. Endoscopic polypectomy was performed for both lesions and the polyps were successfully removed. The resected polyps were 11 × 10 mm and 13 × 12 mm in size, respectively. The polyps were histologically diagnosed as tubulovillous and tubular adenomas, respectively, with no evidence of malignancy. Endoscopic polypectomy provides histological confirmation of adenoma of the gastrointestinal tract, and it is frequently applicable to the duodenum.     

Nature of white opaque substance in gastric epithelial neoplasia as visualized by magnifying endoscopy with narrow‐band imaging

Background and Aims: Magnifying endoscopy (ME) with narrow‐band imaging (NBI) revealed a white opaque substance (WOS) within the superficial part of the gastric neoplasia; however, its nature has remained obscure. A WOS noted within the duodenum was reported to comprise lipid droplets (LD) absorbed by the duodenal epithelium. We attempted to ascertain whether the WOS within gastric neoplasia could also comprise LD and whether the presence of this WOS could be correlated with a specific phenotype. Methods: Forty‐three patients with early gastric epithelial neoplasia underwent ME with NBI. The presence or absence of WOS in the neoplasias was recorded based on the findings of ME with NBI. One biopsy specimen was taken from each of the neoplasias. Cryostat sections underwent oil red O staining for LD. Serial sections were immunostained using the first antibody of CD10, MUC2, CDX2, human gastric mucin, MUC5AC and MUC6. The tissue phenotype was classified as intestinal (I), gastric (G) and gastrointestinal (GI) type based on the results of immunostaining. In total, 49 gastric neoplasias from 43 patients were investigated. Results: Prevalence of LD in WOS‐positive versus WOS‐negative lesions was 96.2% (25/26) and 4.3% (1/23), respectively (P < 0.001, Fisher's exact test). WOS was present in GI‐ and I‐type lesions, but not in G‐type lesions. Conclusions: WOS may be LD that have been accumulated in the superficial part of the gastric neoplasia of a certain intestinal phenotype.     

Pedunculated Brunner's gland hamartoma of the duodenum causing upper gastrointestinal hemorrhage

A case of pedunculated Brunner's gland hamartoma (BGH) of the duodenum causing upper gastrointestinal (GI) hemorrhage is reported. The patient was a 47-year-old man who visited our hospital for further evaluation of tarry stools and shortness of breath.Endoscopic examination of the upper digestive tract revealed a large peduncular polyp with bleeding,about 30 mm in diameter, arising from the wall of the second portion of the duodenum. GI bleeding occurred from the base of the stalk of the polyp. Endoscopic polypectomy was performed. Histological examination of the specimen revealed that the main body of the polyp contained several lobules of mature Brunner'gland with areas of cystic dilatation. The surface epithelium consisted of normal duodenal mucosa with areas of focal ulceration. This polyp was diagnosed as a BGH. The symptom of tarry stools resolved after endoscopic resection. Our case shows that treatment is necessary for duodenal BGH if GI bleeding occurs.     

Minute signet ring cell carcinoma occurring in gastric hyperplastic polyp

We describe a 45-year-old woman with minute signet ring cell carcinoma occurring in a gastric hyperplastic polyp. A biopsy specimen obtained from the gastric hyperplastic polyp revealed signet ring cell carcinoma. Endoscopic mucosal resection （EMR） was performed to confirm the diagnosis. Histological examination of the EMR specimen revealed focal signet ring cell carcinoma in the hyperplastic polyp. There are few cases of gastric hyperplastic polyp associated with signet ring cell carcinoma.     

Two cases of early gastric cancer arising in gastric hyperplastic polyps

We report 2 cases of early gastric cancer arising in hyperplastic polyps. The first case was 6mm in diameter, tub1, in an intestinal phenotype. The second case was 10mm in diameter, pap, in a gastric phenotype. Before resection, their biopsies had been diagnosed as atypical hyperplastic polyps. These cases suggest that small gastric hyperplastic polyps possess a certain malignant potential. If a hyperplastic polyp shows atypia in the biopsy, a complete resection should be considered.     

EUS mini probes in diagnosis of cystic dystrophy of duodenal wall in heterotopic pancreas： A case report

Cystic dystrophy of the duodenal wall is a rare condition characterized by the development of cysts in heterotopic pancreatic tissue localized in the duodenal wall. A 38-year-old man was admitted to the hospital for abdominal pain and vomiting after food intake. The diagnosis of acute pancreatitis was initially suspected. Abdominal ultrasound examination revealed thickening of the second portion of duodenal wall within which, small cysts (diameter, less than 1 cm) were present in the vicinity of pancreatic head.The head of pancreas appeared enlarged (63 mm&#215;42 mm)and hypoechoic. Upper endoscopy and barium X-ray series were performed revealing a severe circumferential deformation, as well as 4 cm long stenosis of the second portion of the duodenum. CT examination revealed multiple cysts located in an enlarged, thickened duodenal wall with moderate to strong post-contrast enhancement. We suspected that patient had cystic dystrophy of duodenal wall developed in the heterotopic pancreas and diagnosis was confirmed by endoscopic ultrasound (EUS). Endoscopi cutrasound (EUS) revealed drcular stenosis from the duodenal bulb onwards. A twenty megaHertz mini-probe examination further showed diffuse (intramural) infiltration of duodenal wall limited to the submucosa and muscularis propria of the second portion of duodenum with multiple microcysts within the thickened mucosa and submucosa, a. Patient was successfully surgically treated and pancreatoduodenectomy was performed. The pathological examination confirmed a diagnosis of cystic dystrophy of a heterotopic pancreas.Endoscopic ultrasonography features allow preoperative diagnosis of cystic dystrophy of a heterotopic pancreas in duodenal wall, with inb‘alumina120 MHz mini probe sonography being more efficient in cases of luminal stenosis.     

PEDUNCULATED INVERTED HYPERPLASTIC POLYP OF THE SIGMOID COLON TREATED WITH ENDOSCOPIC POLYPECTOMY

A case of inverted hyperplastic polyp of the sigmoid colon is reported. The patient was a 67‐year‐old woman who visited our hospital for further evaluation of constipation. Colonoscopy revealed a pedunculated polyp with linear central depression, about 12 mm in diameter, in the sigmoid colon. Excluding the polyp, there was no lesion in the colorectum. Endoscopic polypectomy was performed. Histological examination of the specimen revealed a stalked polyp that had scattered goblet cells and elongated tubules with serrated profiles in the superficial portion. The nodules of deep tubules impinged on the muscularis mucosae. Proliferation of fibromuscular tissue was not seen in the polyp. There was no evidence of malignancy. This polyp was diagnosed as an inverted hyperplastic polyp. Pedunculated‐type inverted hyperplastic polyp of the colon is rare.     

EARLY DUODENAL CARCINOMA SUCCESSFULLY TREATED BY ENDOSCOPIC MUCOSAL RESECTION

Two cases with duodenal carcinoma successfully treated by endoscopic mucosal resection are reported. Case 1 had a semipedunculate polyp, and case 2 had a flat elevated lesion with a central depression in the second portion of the duodenum. Histologic examination showed tubular adenocarcinoma in adenoma in case 1 and an intramucosal adenocarcinoma in case 2, indicating that complete endoscopic resection had been achieved in both cases. Endoscopic mucosal resection appears to be a safe and efficient method for management of early carcinoma of the duodenum as well as in other regions of the gastrointestinal tract.     

EARLY GASTRIC CANCER WITH WIDESPREAD DUODENAL INVASION WITHIN THE MUCOSA

We report a rare case of early gastric cancer confined to the mucosal layer with extensive duodenal invasion, curatively removed with distal gastrectomy. An 84‐year‐old Japanese woman was referred to our hospital with gastric cancer. A barium meal examination and esophagogastroduodenoscopy revealed an irregular nodulated lesion measuring 6.5 x 5.5 cm in the gastric antrum and an aggregation of small nodules in the duodenal bulb. A biopsy specimen showed well‐differentiated adenocarcinoma. The patient underwent distal gastrectomy with partial resection of the duodenal region containing the tumor and regional lymph node dissection, with no complication. Histological examination of the resected tissue confirmed well‐differentiated adenocarcinoma limited to the mucosal layer and without lymph node metastasis. The cancer extended into the duodenum as far as 38 mm distant from the pyloric ring, and the resected margins were free of cancer cells. Gastric cancer located adjacent to the pyloric ring thus has the potential for duodenal invasion, even when tumor invasion is confined to the mucosal layer. In such cases, care should be taken during examinations to detect duodenal invasion, and the distal surgical margin must be negative given sufficient duodenal resection.     

Diagnostic value of endoscopic and endoscopic ultrasound characteristics of duodenal submucosal tumour-like heterotopic gastric mucosa

OBJECTIVE:

Recent studies have reported that duodenal heterotopic gastric mucosa (HGM) has been observed in 8.9% of patients who undergo esophagogastroduodenoscopy. However, there are few reports concerning the endoscopic and endoscopic ultrasound characteristics of submucosal tumour-like HGM in the duodenum.

METHODS:

Endoscopic, endoscopic ultrasound (EUS) and histological findings were analyzed in six patients with submucosal tumour-like HGM, which were confirmed by pathological examination of biopsy or endoscopic polypectomy specimens.

RESULTS:

Endoscopically, the lesions appeared as a solitary, sessile submucosal tumour-like mass with a depression at the top. In four of six patients, small granular structures were found in the depressed area of the mass. On EUS, all masses demonstrated a heterogeneous pattern, among which four patients presented anechoic areas while two patients showed no anechoic areas. All lesions were localized within the mucosa and submucosa on EUS. Histologically, they consisted of gastric glands and some dilated glands, and were covered with normal duodenal epithelium. In four of six lesions, the tumours were composed of gastric-type foveolar epithelium showing papillary growth, fundic glands and pyloric glands, while the others consisted of gastric-type foveolar epithelium and pyloric glands.

CONCLUSION:

A heterogeneous pattern on EUS and small granular structures on esophagogastroduodenoscopy represent valuable diagnostic features of submucosal tumour-like HGM.     

MAGNIFYING ENDOSCOPIC FINDINGS OF THE SURFACE STRUCTURE OF NON‐CANCEROUS MUCOSA SURROUNDING DIFFERENTIATED AND UNDIFFERENTIATED GASTRIC CARCINOMA

Background: Several reports have described the usefulness of magnifying endoscopy in observing the surface structure in gastric neoplasia. The aim of the present study was to evaluate the characteristics of the surface structure of non‐cancerous mucosa surrounding gastric cancer. Methods: Sixty Japanese patients with early gastric cancer were enrolled in this study. We observed the non‐cancerous gastric mucosa surrounding gastric carcinoma by magnifying endoscopy and classified the magnified view into four patterns: (A) dotted; (B) short‐linear; (C) striped; and (D) granular, according to Sakaki's classification. Results: All patients were diagnosed as having Helicobacter pylori infection, and histological evaluation revealed 46 types of differentiated and 14 types of undifferentiated‐type gastric carcinomas. There were significant differences in the gender, age and endoscopic‐atrophic‐border scale between patients with these two types. In all, the surface structure at 240 points (4 points each in 60 patients) of non‐cancerous mucosa was observed by magnifying endoscopy. The prevalences of the surface patterns of the mucosa surrounding differentiated carcinoma were: A, 1.1%; B, 8.1%; C, 28.3%; D, 62.5%, and those of the mucosa surrounding undifferentiated carcinoma were: A, 8.9%; B, 73.2%; C, 14.3%; D, 3.6%. There were significant differences in the surface structure of the non‐cancerous mucosa surrounding differentiated and undifferentiated gastric carcinoma. Conclusion: The microsurface structure of the gastric mucosa surrounding gastric cancer lesions differed between patients with differentiated and undifferentiated gastric cancer. These findings are expected to be useful for the early detection of gastric carcinoma lesions or for the determination of extensions of carcinoma lesions.