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Focal Hypertrophic Gastric Folds Masquerading as a Gastric Neoplasm
Samir Nath, M.D.
Marc Shabot, M.D.
William Nealon, M.D.
Shu-Yuan Xiao, M.D.
Swarupa Gadre, M.D.
Manoop S. Bhutani, M.D.
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Keywords
Endoscopic ultrasound, hypertrophic gastric folds.
Introduction
Hypertrophic gastritis rarely presents as a focal mass lesion. But when encountered, malignancy needs to be excluded taking into account the clinical scenario. A highly unusual case that required surgical resection for definitive exclusion of malignancy is being reported.
Methods for Image Capture/Processing
Saved as JPEG and edited in Microsoft Photo Editor.
Case/Body
A 76-year-old Caucasian male underwent a colonoscopy and an EGD for evaluation of iron deficiency anemia that required blood transfusion. He was taking 325 mg of Aspirin daily and had no gastrointestinal symptoms. He did not report any overt GI bleeding and his stool was heme negative. Colonoscopy was unremarkable except for internal hemorrhoids. EGD revealed a 4 cm sessile mass in the gastric fundus (Figure 1).
Biopsy of the lesion showed moderate chronic active gastritis. Antral biopsies showed chronic active gastritis with intestinal metaplasia. Both biopsies were positive for Helicobacter pylori. EGD was repeated two months after triple therapy for H. Pylori eradication. The sessile mass in the gastric fundus appeared unchanged. Repeat antral biopsies were normal but biopsies of the mass showed mild chronic gastritis. All repeat biopsies stained negaive for H. Pylori. Another EGD performed five months later revealed the mass to be unchanged and endoscopic biopsies again showed mild chronic gastritis with no evidence of malignancy. An EUS revealed a complex sessile lesion underneath which the muscularis propria could not be traced completely and the lesion was not considered suitable for endoscopic mucosal resection (Figure 2).
Based on endoscopic and EUS images as well as the persisient nature of the atypical lesion, a neoplastic focus in its deeper portions could not be completely ruled out despite negative endoscopic biopsies. Due to diagnostic uncertainty and concern for an underlying neoplasm, the patient underwent an open laparotomy with a focal resection of the lesion. The resected specimen contained the mass lesion, with wide margins. Microscopically, the mass lesion exhibited marked gastric gland hypertrophy, with no significant inflammation. There was prominent hyperplasia of the parietal cells (Figure 3). Focal small cystically dilated glands were also noted. The surrounding mucosa, however, exhibited marked atrophy, chronic inflammation, with complete loss of fundic type glands (replaced by antral glands), and with focal intestinal metaplasia.
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Figure 3 |
Discussion
This case demonstrates the clinical, endoscopic, endosonographic, and pathological features of a highly unusual phenomenon of focal hypertrophic gastric folds associated with H. pylori infection that persisted despite eradication of H. pylori. The major clinical issue that arose in this case was that a neoplastic lesion could not be conclusively ruled out despite benign endoscopic pinch biopsies. Other methods such as large particle biopsy, biopsy on biopsy, snare biopsy, or EUS guided FNA of the lesion could have been attempted prior to surgery. However, these were not performed given the unusual nature of the lesion that was persistent with on going anxiety on behalf of the patient and his primary physician about this lesion. Proceeding to surgical excision was opted, as even these other methods of sampling mentioned above (if negative for malignancy) would not have conclusively ruled out a neoplastic lesion due to the possibility of sampling error. In conclusion, the endoscopic, endosonographic, and pathological findings of focal hypertrophic gastric folds that may present as a mass lesion are described. Sometimes, this entity may require surgical excision for definitive diagnosis and exclusion of a neoplastic process.
References
1. Songur Y , Okai T, Watanabe H, Motoo Y, Sawabu N. Endosonographic evaluation of giant gastric folds. Gastrointestinal Endoscopy 1995; 41: 468-74.
2. Oknabu H, Hata J, Haruma K, Hara M, Nakamura K, Tanaka S, Chayma K. Giant gastric folds: differential diagnosis at US. Radiology 2003;226:686-90.
3. Stolte M, Batz C, Eidt S. Giant fold gastritis- a special form of Helicobacter pylori associated gastritis. Z Gastroenterol. 1993; 31(5):289-93.
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