Designed by Michelle Snavely

AbstractGastritis Cystica Profunda (GCP) is by a rare but benign submucosal lesion usually occurring in the fundus of the stomach. A 69 year old man with no past surgeries presented with diffuse abdominal pain associated with melena for 2 weeks. His only medication was a daily ASA 81 mg and had a hemoglobin drop from baseline 15.4 g/dl to 12.9 g/dl. EGD showed a 3 cm submucosal mass at the greater curvature of the stomach with associated stigmata of bleeding. Biopsies of the lesion revealed chronic gastritis, negative for intestinal metaplasia. He was referred for EUS which demonstrated the lesion to arise from submucosal layer 3 with well defined borders, it was heterogenous (hypoechoic & isoechoic) suggestive of ectopic pancreas vs. GIST. He was referred for surgical excision because of the size of the lesion and its propensity to bleed. The patient declined surgical referral and instead underwent 6-month surveillance with repeat EUS. A submucosal gastric lesion was seen again but with central umbilication, hyperechoic and with central cystic space. Tunnel biopsies revealed gastritis cystic profunda with localized atrophy and intestinal metaplasia. The gastric lamina propria displayed florid stromal hyperplasia reminiscent of that seen in inflammatory fibroid polyps. Patient was reassured and scheduled for a repeat EGD w/ EUS in another 6 months.

References:1. Itte V, Mallick I, Moore P. Massive Gastrointestinal Hemorrhage due to Gastritis Cystica Profunda. Cases Journal. 2008; 85: 1-3 . 2. Kurland J, DuBois S, et al. Severe Upper-GI bleed caused by Gastritis Cystica Profunda. Gastrointestinal Endoscopy. 2006; 63: 716-717.3. Park C, Park J, Jung C, et al. Early gastric cancer associated with Gastritis Cystica Polyposa in the Unooperated Stomach treated by Endoscopic Submucosal Dissection. Gastrointestinal Endoscopy. 2009; 69: e47-e50.4. Park J, Myung S, et. Al. Endoscopic Treatment of Gastritis Cystica Polyposa found in an Unoperated Stomach. Gastrointestinal Endoscopy. 2001; 54: 101-103.

Division of Internal Medicine, Albany Medical College and Center and *Stratton VA Medical Center, Albany, NY**Buffalo VA Medical Center, Buffalo, NY

Wallace J. Wang, MD, Andy J. Thanjan, MD, *Raina Patel, MD, *Christopher Ashley, MD, **Shahid Mehboob, MD

Upper GI Bleed Caused by Gastritis Cystica Profunda in an Unoperated Stomach

Conclusions* We present a rare case of GCP presenting as an upper GI bleed in a patient who has never undergone gastric surgery.

* GCP at a gastroenterostomy site may be a precancerous lesion via the downward adenocystic proliferation of glands.

* In the setting without any history of gastrectomy, its removal and histopathologic confirmation should be carried out due to its premalignant implications.

* GCP patients have not been observed for long periods of time; thus treatment and timing of excision is unknown. More research needs to be conducted in the pathogenesis of GCP.

Background* Gastritis Cystica Profunda is by a rare but benign submucosal lesion usually occurring in the fundus of the stomach.

* It is usually associated with previous gastric surgery. GCP may be precancerous as carcinoma is frequently found at old gastrojejunostomy stomas.

Discussion* We have a case of a 69 y/o male with no past surgeries presenting with diffuse abdominal pain, melena of 2 weeks duration. EGD showed a 3cm submucosal mass at the greater curvature of the stomach with bleeding stigmata; biopsy revealing only chronic gastritis. An EUS was performed showing submucosal heterogenous echogenicity whereupon repeat 6 month surveillance EUS with tunnel biopsy revealed gastritis cystic profunda with localized atrophy and intestinal metaplasia. The gastric lamina propria displayed florid stromal hyperplasia reminiscent of that seen in inflammatory fibroid polyps.

* The pathogenesis of GCP is related to ischemia, chronic inflammation and the presence of foreign body at the previous surgical site.

* GCP can present clinically as bloating, abdominal discomfort, gastric obstruction, mucosal ulceration and bleeding.

* The disruption of muscularis mucosa integrity causes downward migration of epithelial contents into the submucosa of the stomach. GCP in the unoperated stomach has thought to be of congenital etiology, mainly because of the absence of prior trauma or gastric ulceration.

* The main findings histologically are elongation of the gastric pits, submucosal invasion by the hyperplastic process and cystic dilatation of the pseudopyloric glands. The foveolae are elongated because of the marked hyperplasia.

* Endoscopically, GCP shows mass-like lesions protruding into the gastric lumen or large polypoid gastric folds.

* GCP can be removed surgically or via endoscopic submucosal dissection.

* Regular monitoring should be done as GCP is a premalignant condition.

10x Medium power, normal gastric mucosa.4x Low power gastric mucsosa showing glands extending

beyond the muscularis mucosae, with chronic inflammation.10x Medium power gastric mucosa showing hyperplasic glands

extending through the muscularis mucosae and intestinal metaplasia.

2 cm subepithelial lesion with central umblication/erosion in the distal gastric body on the greater curvature.

The hyperechoic lesion arises from submucosa (3rd layer), measuring 23.5 mm x 13.2 mm. It has a central anechoic space (without doppler flow). The margins are well defined and smooth. Underlying muscularis

propria appears normal.