The clinical and endoscopic spectrum of the watermelon stomach.

The watermelon stomach is an uncommon but treatable cause of chronic gastrointestinal bleeding. We report our experience with the clinical and endoscopic features of 45 consecutive patients treated by endoscopic Nd:YAG laser coagulation. The prototypic patient was a woman (71%) with an average age of 73 years (range of 53-89 years) who presented with occult (89%) transfusion-dependent (62%) gastrointestinal bleeding over a median period of 2 years (range of 1 month to > 20 years). Autoimmune connective tissue disorders were present in 28 patients (62%), especially Raynaud's phenomena (31%) and sclerodactyly (20%). Atrophic gastritis occurred in 19 of 19 (100%) patients, with hypergastrinemia in 25 (76%) of 33 patients tested. Antral endoscopic appearances included raised or flat stripes of ectatic vascular tissue (89%) or diffusely scattered lesions (11%). Proximal gastric involvement was present in 12 patients (27%), typically in the presence of a diaphragmatic hernia. Endoscopic laser therapy after a median of one treatment (range of 1-4) resulted in complete resolution of visible disease in four patients (13%) and resolution of > 90% in 24 patients (80%). Hemoglobin levels normalized in 87% of patients over a median follow-up period of 2 years (range of 1 month to 6 years) with no major complications. Blood transfusions were not necessary after laser therapy in 86% of 28 initially transfusion-dependent patients. The characteristic clinical, laboratory, and endoscopic features allow for a confident diagnosis that can lead to successful endoscopic treatment.     

Glomus tumor in the stomach:Computed tomography and endoscopic ultrasound findings

A 57-year-old man presented with intermittent dull abdominal pain after a period of 1 year.Abdominal computed tomography(CT) was performed.Except for the endoscopy,the work-up for possible medical causes remained inconclusive.An open-abdomen,partial surgical excision of the stomach was performed after the unsuccessful endoscopic resection.The pathology report revealed a glomus tumor of the stomach.Importantly,glomus tumors of the stomach are rare and are almost always benign.Therefore,the most important current role of imaging associated with the diagnostic approach and therapeutic plan for a glomus tumor is to differentiate it from other gastric submucosal tumors(SMTs).We report this case with representative radiologic findings,including CT and endoscopic ultrasound(EUS) reports,and also correlate them with clinical and pathologic presentations that can help in the early detection and differentiation of gastric SMTs from other SMTs.As such,the purpose of this report is to provide a better understanding of relevant CT and EUS features.Alternative treatments should be considered carefully according to the imaging results.     

Characteristic endoscopic and magnified endoscopic findings in the normal stomach without Helicobacter pylori infection

BACKGROUND AND AIMS: The aim of this study was to clarify the endoscopic features of the Helicobacter pylori (H. pylori)-free stomach by examining the arrangement of minute points visible on the corpus. Since these points were clarified by magnifying endoscopy as collecting venules, this finding was termed 'regular arrangement of collecting venules (RAC)'. The findings from more endoscopic studies are presented and the differences between magnified views of the normal and H. pylori-infected corpus and antrum are described in particular. METHODS: The study group consisted of 557 patients who were subjected to endoscopy and checked for H. pylori. The RAC in each patient was assessed. Magnifying endoscopy in 301 patients was used to examine the corpus and in 94 patients to examine the antrum. RESULTS: One hundred and fifty-eight patients had normal stomachs without H. pylori. We diagnosed 389 patients with H. pylori gastritis. In 10 patients H. pylori was not detected, but inflammation was present. Of the 158 patients with H. pylori-negative normal stomachs, 151 had RAC. As a determinant of the normal stomach without H. pylori infection, the presence of RAC had 93.8% sensitivity and 96.2% specificity. All 30 patients with H. pylori-negative normal stomachs had a well-defined ridge pattern (wDRP) on the antrum as observed under magnifying endoscopy. As a determinant of the normal stomach without H. pylori infection, wDRP had a specificity of 100%, but a sensitivity of only 54.5%. CONCLUSIONS: The presence of RAC is characteristic of a normal stomach without H. pylori. Magnified views of the normal antrum were different from that of the normal corpus.     

Efficacy of magnifying endoscopy with flexible spectral imaging color enhancement in the diagnosis of colorectal tumors

Background

Magnifying endoscopy with flexible spectral imaging color enhancement (FICE) is an image-enhanced endoscopy that captures the surface and vascular patterns of colorectal tumors. We evaluated and compared FICE magnification to narrow-band imaging (NBI) magnification.

Methods

Flexible spectral imaging color enhancement or NBI magnification was performed to the visualize surface and vascular patterns of colorectal tumors, classified into 4 types: Type A, Type B, Type C1/C2, and Type C3, as previously reported. A total of 235 colorectal tumors were examined. The correlations between classifications found by FICE or NBI magnification and histopathological diagnoses were examined. Image evaluation was validated by assessing inter-observer and intra-observer agreements on examinations.

Results

Twenty-eight hyperplastic polyps (HPs), 115 tubular adenomas (TAs), 72 mucosal and slightly invaded submucosal cancers (M-sSM), and 20 massively invaded submucosal cancers (mSM) were diagnosed. By FICE magnification, HP and TA were observed in 93.3 and 6.7% of Type A (15 lesions), respectively. TA, M-sSM, and HP were observed in 82.6, 15.4, and 2.0% of Type B (52 lesions), respectively. M-sSM, TA, and mSM were observed in 50.0, 46.0, and 4.0% of Type C1/2 (50 lesions), respectively. mSMs were observed in all 7 Type C3 lesions. In diagnosing mSM in Type C3, the sensitivity and specificity of FICE magnification were 77.7 and 100%, respectively, compared to those of NBI, at 63.6 and 99.0%, respectively. Imaging evaluation was validated accurately by intra- and intra-observer measurements showing consistent results.

Conclusions

The classification of colorectal tumors by FICE magnification correlated well with the histopathological diagnoses, similar to findings for NBI magnification. FICE magnification can be evaluated accurately with the same diagnostic classifications as those used for NBI magnification.     

Clinical course and magnifying endoscopic findings of fine lesions of the large intestinal mucosa in Crohn's disease

"Worm-eaten" appearance (WEA) is a fine lesion of Crohn's disease observed in apparently normal rectal mucosa by magnifying endoscopy. Magnifying endoscopy has now been performed following application of methylene blue on 37 occasions in 27 patients with Crohn's disease, and the occurrence of WEA was reviewed in relation to the duration and extent of disease. The frequency of WEA was 75% in patients with a history of less than five years and 77% in those who had had the disease for more than five years. In the active stage, the frequency was 85% and 100% respectively, and the degree of WEA also increased. The detection rate of granulomata in regions of WEA was 53% when the clinical history was less than five years and 33% when five years or more. In active disease, granulomata were found in 70% and 67% respectively. The large intestine other than the rectum was reviewed in eight patients with ileitis. WEA and granulomata were observed throughout the large intestine including the cecum, especially when the ileal disease was active.     

Correlation between endoscopic biopsy findings and sonograms of the abdomen in stomach cancer

35 out of 57 patients with gastric carcinoma presented with a so called "target" pattern. In cases with distal cancer the more advanced cases with endoscopic types Borrmann III/IV showed this sign more frequently than less advanced forms, i.e. suspected early cancer, Borrmann I or Borrmann II. On the other hand in endoscopically advanced cancers Borrmann III/IV a thickening of the gastric wall was more frequent in distal than in proximal localization of carcinoma. The presence of target sign in abdominal ultrasound did, statistically, not influence gastric resection. Other findings, which were observed exclusively in gastric cancer type Borrmann III/IV, like infiltration to the surrounding (pancreas, liver), liver metastasis, and/or ascites, were decisive. Additional sonography of the abdomen is, therefore, a valuable preoperative diagnostic procedure in gastric cancer beside upper GI endoscopy and biopsy.     

Diagnosis of endoscopic Barrett’s esophagus by transnasal flexible spectral imaging color enhancement

Background  

The diagnosis of endoscopic Barrett’s esophagus (BE) has been under discussion for the past decade because palisade vessels may be obscured by inflammation or the location of upper end of gastric fold may be diversely changed. The flexible spectral imaging color enhancement (FICE) system can reconstruct improved spectral images decomposed from ordinary endoscopic images with free selection of three wavelengths, and can provide non-magnified images with high light intensity.     

Treatment of watermelon stomach (GAVE syndrome) by means of endoscopic argon plasma coagulation (APC): long-term outcome

We report on 17 patients with GAVE-syndrome (gastric antral vascular ectasia) treated by means of endoscopic argon plasma coagulation (APC). 16 of 17 patients presented with iron deficiency anemia; transfusion-dependent anemia was noted in 11 patients (65%). Resolution of the gastric angiectasia could be achieved in all patients by endoscopic APC after 1-4 treatment sessions. Endoscopic follow-up revealed recurrence of GAVE in 5 patients (requiring further treatment sessions). Mean pretreatment hemoglobin level of 78 g/l improved to 115 g/l after treatment. Only one patient needed post-treatment transfusions; she had refused further endoscopy. The mean follow-up was 30.4 months (range 1-65). In one case circumferential scarring of the antrum led to asymptomatic stenosis 6 months after APC; at the same time early recurrence of extensive angiectasia occurred. Billroth I resection was performed. No other complications were observed. Our results show that argon plasma coagulation is an effective and safe treatment for gastrointestinal blood loss due to GAVE syndrome (watermelon stomach). Control endoscopies are indicated in order to recognize and treat recurrence of angiectasia on time.     

Recognition of endoscopic diagnosis in differentiated-type early gastric cancer by flexible spectral imaging color enhancement with indigo carmine

Background/Aims: To evaluate the usefulness of flexible spectral imaging color enhancement with indigo carmine (I-FICE) in early gastric cancer (EGC) demarcation. Methods: The study participants were 29 patients with differentiated-type EGC. The endoscope was fixed and images of the same area of EGC demarcations in each lesion were obtained using four different methods (WLE, flexible spectral imaging color enhancement (FICE), CE, and I-FICE). FICE mode at R 550 nm (Gain: 2), G 500 nm (Gain: 4), and B 470 nm (Gain: 4) was used. Four endoscopists ranked the images obtained by each method on the basis of the ease of recognition of demarcation using a 4-point system. We calculated the standard deviation of pixel values based on L*, a*, and b* color spaces in the demarcation region (Lab-SD score). Results: The median ranking score for I-FICE images was significantly higher than that obtained from the other methods. Further, the average Lab-SD score was significantly higher for I-FICE images than for images obtained by the other methods. There was a good correlation between the ranking score and Lab-SD score. Conclusion: EGC demarcations were most easily recognized both subjectively and objectively using I-FICE image, followed by CE, FICE and WLE images.     

Minute findings by magnifying colonoscopy are useful for the evaluation of ulcerative colitis

BACKGROUND: Colonoscopy has an important role in the diagnosis of ulcerative colitis. However, colonoscopic findings are inadequate for the prediction of relapse without histologic examination. In this study, the role of magnifying colonoscopy in ulcerative colitis was evaluated. METHODS: One hundred sixteen magnifying colonoscopy observations were made in 61 patients with ulcerative colitis between January 1994 and October 1998. A simple classification of magnifying colonoscopic findings into 5 categories was devised as follows: regularly arranged crypt openings, villous-like, minute defects of epithelium, small yellowish spots, and coral reef-like appearance. The colonoscopic findings by classification were compared with histopathologic findings, and the usefulness of the classification for predicting relapse was prospectively analyzed in 18 patients. RESULTS: Compared with grade as determined by conventional colonoscopy, there was a better correlation between the classification of findings by magnifying colonoscopy and histopathologic findings (r(2) = 0.665, 0.807, respectively). Of 18 patients studied prospectively, 7 of 9 with minute defects of epithelium relapsed within 6 months, and the cumulative nonrelapsing rate was significantly lower in patients with minute defects of epithelium compared with those without minute defects of epithelium (p = 0.0059). Moreover, minute defects of epithelium was found to be a significant independent predictive factor for relapse (multivariate analysis, Cox proportional hazards model; p = 0.0203). CONCLUSIONS: Our proposed classification of magnifying colonoscopic findings in patients with ulcerative colitis is useful for the evaluation of disease activity and for the prediction of periods of remission.