DUODENAL ADENOMA OF GASTRIC FOVEOLAR PHENOTYPE IN THE SECOND PORTION OF THE DUODENUM

We describe a rare case of duodenal adenoma of a gastric phenotype in the second portion of the duodenum. An 85‐year‐old Japanese man with a history of left nephrectomy was admitted to our hospital with a cerebral transient ischemia attack. Screening upper gastrointestinal endoscopy revealed a subpedunculated polyp with a reddish, erosive, glossy appearance, and a granular surface just above the papilla of Vater in the second portion of the duodenum, which on biopsy was diagnosed as a hyperplastic polyp. Hypotonic duodenography revealed a subpedunculated polyp with irregular granular surface, measuring approximately 20 mm in size, in the second portion of the duodenum. Endoscopic total resection for biopsy was performed. The histopathological examination of the polypectomied specimens revealed an adenoma with moderate dysplasia mimicking gastric foveolar epithelium or hyperplastic polyp accompanied by abundant mucin production. Immunohistochemistry revealed a complete gastric phenotype, suggesting it had probably arisen from heterotopic gastric mucosa. The present case is the eleventh case of duodenal neoplasia arising from heterotopic gastric mucosa and the sixth case of neoplasia with gastric phenotype found in the second portion of the duodenum reported in the world.     

Heterotopic gastric mucosa with focal intestinal metaplasia and squamous epithelium in the rectum

Heterotopic gastric mucosa has been described in all levels of the gastrointestinal tract. However, gastric heterotopia of the rectum is a rare finding. It is usually reported along with polyp located in the rectum between 5 and 8 cm from the anal verge. The most common symptom is painless rectal bleeding, and non-specific gastrointestinal symptoms may also be presented. We report an incidentally found case of a 46-year-old man without any gastrointestinal symptoms. The pathology showed gastric mucosa and squamous epithelium and focal intestinal metaplasia. This finding could be a clue as to the origins of the heterotopic gastric mucosa. Although there are no guidelines for treatment or the follow-up period, regular endoscopic surveillance is necessary for gastric cancer screening.     

Esophago-bronchial fistula treated by the Over-The-Scope-Clipping (OTSC) system with argon beam electrocoagulation: A case report

Rationale:An esophago-bronchial fistula is one of the rare postoperative complications of esophageal cancer. There are various medical treatments, including suturing, endoscopic clip, and fibrin glue. However, these treatments often lead to unsatisfactory results, causing physicians to opt for surgical alternatives. The Over-The-Scope-Clipping (OTSC) system offers an alternative method for fistula closure. It can capture a large amount of tissue and is able to compress the lesion until it has fully healed. However, data indicating the efficacy of OTSC for esophago-bronchial fistula are limited.Patient concerns:A 64-year-old man presented with an esophago-bronchial fistula after surgery for esophageal cancer. We chose to use a stent as the first line of treatment, but the fistula did not close.Diagnoses:Intractable esophago-bronchial fistula associated with esophageal surgery.Interventions and Outcomes:On the 94th postoperative day, fistula closure with OTSC was performed, and no leakage of the contrast agent was observed during fluoroscopy. We also attempted to close the fistula by combining OTSC and argon plasma coagulation (APC) to burn off the scar tissue from around the fistula. The fistula gradually shrank after a total of 4 rounds of OTSC, and closure of the fistula was achieved on the 185th postoperative day. There were no adverse events during the treatment of this case.Lessons:We demonstrate that OTSC is useful in the management of esophago-bronchial fistulas, and may become a standard procedure for the endoscopic treatment of esophago-bronchial fistulas, replacing the use of stents, clips, or glue.     

Low-grade dysplasia in an adenomatous polyp of the esophagus developing on pyloric-type heterotopic gastric mucosa treated with endoscopic mucosal resection: a case report

A 72-year-old woman with an unremarkable medical history underwent an upper gastrointestinal endoscopy in May 2002 because of dyspepsia. An examination showed a pedunculated polyp lesion in an inlet patch on the posterior wall of the esophagus, 20 cm distant from the incisors and measuring 1.5 cm. Forceps biopsies were obtained, and the pathological analysis showed a gastric-like mucosa with well-differentiated pyloric glands below an atrophic squamous epithelium; most of the glands were lined with atypical cells, compatible with low-grade dysplasia. Histological examination after endoscopic removal showed a low-grade dysplasia in an adenomatous polyp of the esophagus developing on pyloric-type heterotopic gastric mucosa (HGM). Three years later, the patient remains well with no evidence of esophageal disease. We review 25 reported cases of adenocarcinoma and 3 cases of high-grade dysplasia arising in HGM.     

Heterotopic gastric mucosa in the upper esophagus: report of a case with a fistula

We report the case of a 36-year-old man with a patch of heterotopic gastric mucosa in the upper esophagus complicated by an esophageal fistula.     

上消化道隧道内镜术后消化道瘘的评估与处理

为探讨上消化道隧道内镜术后消化道瘘的评估和处理方法,回顾性分析2012年1月—2022年10月于复旦大学附属中山医院内镜中心诊疗的15例上消化道隧道内镜术后发生消化道瘘患者的临床资料。患者经综合治疗后消化道瘘均成功愈合。3例患者采用了金属夹夹闭瘘口并留置胃管;10例患者采用了胃管联合小肠营养管置入术,其中7例胃管直接置入瘘腔中引流;2例患者接受了食管覆膜支架联合小肠营养管置入术。5例患者接受过创面组织胶喷洒;2例患者在瘘口缩小后,接受了热活检钳或氩离子凝固术灼烧瘘口,行尼龙绳+金属夹荷包缝合。由此可见,隧道内镜术后消化道瘘是复杂的术后并发症,需要早期发现、仔细评估和综合处理。     

Frequency,histopathological findings,and clinical significance of cervical heterotopic gastric mucosa (gastric inlet patch): a prospective study in 300 patients

The frequency and clinical significance of heterotopic gastric mucosa in the upper esophagus is not sufficiently known. Heartburn or dysphagia could result from mucin and/or acid production in this area. We undertook a prospective study in 300 patients with special attention of the endoscopist to this area. Moreover, clinical symptoms were determined by questionnaire before performing endoscopy. A total of 33/300 (11%) of patients had at least one histologically proven gastric inlet patch without gender or age preference. In 20/33 (61%) cases, the heterotopic gastric mucosa was classified as mixed type, in 8/33 (24%) as oxyntic, and in 5/33 (15%) as mucoid. Helicobacter pylori was present in none of the cases. There was no significant association to the presence of a hiatal hernia, reflux esophagitis, Barrett's esophagus, or gastric/duodenal ulcer. Moreover, there was no association to the reported grade of heartburn in the upper or lower part of the esophagus, recurrent hoarseness, or dysphagia. When thorougly performed, heterotopic gastric mucosa is a quite frequent finding in endoscopy of the upper gastrointestinal tract. The presence of this gastric mucosa in the upper third of the esophagus seems to be rarely the cause of clinical symptoms and little prone to complications.     

Presternal gastric bypass for late postpneumonectomy esophagopleural fistula

SUMMARY: A 71-year-old diabetic patient underwent right pneumonectomy with wide mediastinal lymph node dissection for lung cancer (right upper lobe). Postoperatively he developed pleura empyema that was successfully treated - drainage and Eloesser window, followed by adjuvant radiotherapy. Two months later he developed an esophagopleural fistula. Due to the patient's physical condition primary repair of the esophageal rupture was considered a high-risk operation. Stenting was also considered as inappropriate due to the existing contamination. Bypassing with the use of the stomach as conduit was preferred due to its simplicity compared to the colon. In order to avoid mediastinum after the postradiation alterations and because of the Eloesser window we adopted a presternal subcutaneous position. Twenty-eight months after the by pass procedure the patient is in good health being able to eat and drink, has gained weight and shows no evidence of malignancy. Presternal gastric esophageal bypass has never been reported as a treatment for esophagopleural fistula. This case report indicates its possible successful use in this debilitating setting, although more experience is needed.     

Endoscopic diagnosis of cervical esophageal heterotopic gastric mucosa with conventional and narrow-band images

AIM:To compare the diagnostic yield of heterotopic gastric mucosa(HGM)in the cervical esophagus with conventional imaging(CI)and narrow-band imaging(NBI).METHODS:A prospective study with a total of 760patients receiving a CI examination(mean age 51.6years;47.8%male)and 760 patients undergoing NBI examination(mean age 51.2 years;45.9%male).The size of HGM was classified as small(1-5 mm),medium(6-10 mm),or large(>1 cm).A standardized questionnaire was used to obtain demographic characteristics,social habits,and symptoms likely to be related to cervical esophageal HGM,including throat symptoms(globus sensation,hoarseness,sore throat,and cough)and upper esophageal symptoms(dysphagia and odynophagia)at least 3 mo in duration.The clinicopathological classification of cervical esophageal HGM was performed using the proposal by von Rahden et al.RESULTS:Cervical esophageal HGM was found in 36of 760(4.7%)and 63 of 760(8.3%)patients in the CI and NBI groups,respectively(P=0.007).The NBI mode discovered significantly more small-sized HGM than CI(55%vs 17%;P<0.0001).For the 99 patients with cervical esophageal HGM,biopsies were performed in 56 patients;37(66%)had fundic-type gastric mucosa,and 19 had antral-type mucosa.For the clinicopathological classification,77 patients(78%)were classified as HGMⅠ(asymptomatic carriers);21 as HGMⅡ(symptomatic without morphologic changes);and one as HGMⅢ(symptomatic with morphologic change).No intraepithelial neoplasia or adenocarcinoma was found.CONCLUSION:NBI endoscopy detects more cervical esophageal HGM than CI does.Fundic-type gastric mucosa constitutes the most common histology.One-fifth of patients have throat or dysphagic symptoms.     

Adenocarcinoma arising from heterotopic gastric mucosa in the cervical esophagus and upper thoracic esophagus: two case reports and literature review

Primary adenocarcinoma arising from heterotopic gastric mucosa (HGM) is rare and the clinicopathological characteristics are not well known. We present two cases of esophageal adenocarcinoma arising from HGM with a review of a case series. Case 1 was a 78-year-old woman who underwent a periodic medical examination without complaining of any symptoms. Preoperative evaluation suggested esophageal adenocarcinoma arising from the HGM. The patient was treated with endoscopic submucosal dissection. Definitive pathological diagnosis confirmed adenocarcinoma arising from the HGM. Case 2 was a 70-year-old man who underwent a medical examination after complaining of dysphagia. Preoperative diagnosis suggested esophageal adenocarcinoma; however, its origin was unclear. The patient was treated with surgical resection. Definitive pathological diagnosis revealed adenocarcinoma arising from the HGM. In this article, the authors report the clinicopathological features of esophageal adenocarcinoma arising from HGM that were collected from a literature review and our cases.     

Recovery of esophageal peristalsis after congenital tracheoesophageal fistula repair in an adult

Summary Congenital tracheoesophageal fistulas are usually recognized during early life and are associated with severe esophageal dysmotilities that supposedly persist after fistula repair. We present the case of a patient with abdominal distension diagnosed to result from congenital tracheoesophageal fistula at the age of 17 years. Prior to surgery, manometry showed aperistalsis in the esophageal body that gradually improved during the 14 months of post-operative follow-up. We hypothesized that the dysmotility was due to increased gastroesophageal reflux or to intragastric distension. Therefore, we studied: (1) the correlation between motility and gastroesophageal reflux before and after surgery, and (2) the effect of isotonic gastric distension on esophageal motility. Our studies demonstrated that one year after surgery gastroesophageal acid reflux remained abnormal and that acute experimental gastric distension had no effect on esophageal motility. In summary, esophageal dysmotility in congenital tracheoesophageal fistula may return to normal after surgical repair; neither acute gastric distension nor gastroesophageal reflux are responsible for the reversible esophageal motor abnormalities.     

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     

Heterotopic gastric mucosa in the upper esophagus. An unknown cause of dysphagia

Heterotopic gastric mucosa in the proximal third of the esophagus is an embryological lesion that has been described in between 1.1% and 10% of gastroscopies. Although most of these lesions are asymptomatic, they can sometimes be accompanied by upper esophageal symptoms due to acid secretion. We present a case of heterotopic gastric mucosa in the proximal third of the esophagus with dysphagia. pH-metry demonstrated acid secretion by these lesions, which was resolved by treatment with proton pump inhibitors.     

Esophageal carcinosarcoma with intramural metastasis

A case of esophageal carcinosarcoma is described herein. A 58-year-old man presented with dysphagia and was admitted to our hospital. Imaging studies revealed a type 3 tumor in the upper intrathoracic esophagus with direct invasion to the left main bronchus. Analysis of a biopsy specimen revealed carcinosarcoma. The patient underwent esophageal bypass and chemoradiotherapy. Eight months after surgery, he died of esophago-bronchial fistula. Autopsy examination revealed liver metastasis, peritoneal dissemination and intramural metastasis. The sarcomatous component was predominant in the intramural and liver metastatic lesions.     

Antral mucosa heterotopy in the duodenal bulb

A case of heterotopic antral mucosa presenting as a typical gastric fold, located in the duodenal bulb, is described. Heterotopic gastric mucosa consisting mainly of fundic-type epithelium is commonly found in the gastrointestinal tract and predominantly in the cervical esophagus and the duodenal bulb. Heterotopic gastric mucosa composed of antral-type epithelium, especially of the size described here, is an extremely rare condition. A knowledge of these lesions is clinically relevant in the differential diagnosis at endoscopy of the upper tract.     

Narrow band imaging facilitates detection of inlet patches in the cervical oesophagus

BackgroundProximal esophageal heterotopic gastric mucosa or so-called inlet patch in the cervical oesophagus is easily missed on endoscopic examination because of its localisation, usually just below the upper oesophageal sphincter. We evaluated the clinical use of narrow band imaging for detection of inlet patches.MethodsIn this prospective, controlled observational study, 1407 subsequent patients underwent oesophagogastroduodenoscopy with or without narrow band imaging on withdrawal of the endoscope in the cervical oesophagus.ResultsOne endoscopist who was not aware of the prospective observation documented 6 (1.17%) cases of inlet patches in 515 oesophagogastroduodenoscopies compared to 4 cases out of 382 (1.05%) performed by the endoscopist who paid special attention to the presence of inlet patches but did not routinely apply narrow band imaging (OR 0.89, CI 95% 0.25–3.20, p = 0.85). In comparison, 17 cases of inlet patches out of 510 (3.33%) were detected by the endoscopist who routinely applied narrow band imaging. The detection rate of proximal oesophageal heterotopic gastric mucosa using narrow band imaging was significantly higher compared to white light endoscopy only (OR 3.06, CI 95% 1.39–6.73, p = 0.005).ConclusionsWithdrawal of the endoscope from the cervical oesophagus using narrow band imaging increased the detection of inlet patches about three-fold compared to standard white light endoscopy.     

Extraintestinal heterotopic gastric tissue simulating acute appendicitis

We describe the case of a 68-year-old otherwise healthy male who presented to our emergency room with signs and symptoms of acute appendicitis. Exploratory surgery revealed a normal appendix. Further examination revealed an enlarged lymph node-like mass of tissue near the appendix, in the ileocecal mesentery. This mass was removed and was found to be inflamed heterotopic gastric tissue. Although reports of heterotopic gastric tissue in the literature are common, we believe that this case represents the first report of inflamed heterotopic gastric tissue simulating appendicitis.     

Efficacy of Endoscopic Prosthesis in T4 Cancer of the Intrathoracic Esophagus

No remarkable improvement has yet been achieved in the survival of patients with advanced intrathoracic esophageal cancer. In particular, patients with complications such as esophago-bronchial fistula or invasion into the mediastinum have an especially miserable prognosis, even with surgical treatment. To improve the quality of life (QOL) of such patients, extensive palliative therapy should be provided. Thus, we have introduced an endoscopic esophageal intubation technique for the treatment of stenosis or perforation in patients with T4 esophageal cancer. Nine patients with unresectable intrathoracic esophageal cancer, complicated by stenosis or perforation, were treated with an endoscopic esophageal prosthesis. Four cases had an esophago-bronchial fistula, and in three the tumor had perforated the mediastinum. The prosthesis was successfully placed under endoscopic guidance in all nine cases. Six patients (66.7%) subsequently resumed oral intake without discomfort, while two had reasonably good outcomes in this regard (efficacy rate; 88.9%). Complications were seen in three patients: mainly chest discomfort, reflux esophagitis and migration of the prosthesis in one patient each. Six patients required prolonged administration of chemotherapeutic agents following prosthesis placement. Mean survival was 123.4±77.0 days. Four of the nine patients died in the hospital. Palliative endoscopic esophageal prosthesis was considered to be useful for patients with advanced esophageal cancer. With this technique, an improvement in QOL was achieved, as sufficient oral intake was facilitated and pulmonary and mediastinal complications due to perforation were diminished.     

Acid secretion from an esophageal inlet patch demonstrated by ambulatory pH monitoring

Heterotopic gastric mucosa may occur throughout the gastrointestinal tract, including the upper esophagus. The capability of this ectopic mucosa to secrete acid has been suggested in different reports. We report for the first time a case of heterotopic gastric mucosa in the upper esophagus complicated by a stricture with secretion of acid demonstrated by prolonged ambulatory pH monitoring. Lansoprazole, 30 mg twice daily, produced symptom resolution, and repeat ambulatory pH showed complete acid suppression in the proximal esophagus.GASTROENTEROLOGY 1998;115:1574-1576     

Endoscopic placement of fibrin sealant as a treatment for a long-standing Boerhaave''s fistula

A 64-year-old man suffered a spontaneous rupture of the esophagus (Boerhaave's syndrome) after an episode of severe retching. He underwent attempted primary repair of the esophageal defect, but unfortunately the repair failed with the development of a persistent esophago-bronchial fistula resistant to extended conservative management. Three hundred and nineteen days after the initial rupture, the fistula was successfully treated with endoscopic placement of fibrin glue. We believe this to be the first reported case of fibrin sealant being used in the treatment of a long-standing fistula resulting from Boerhaave's syndrome.