Case PresentationCase PresentationCase PresentationCase Presentation

…… a nice lady with a nice lady with yydyspepsia and dyspepsia and melenamelena……

Dr. Evgeny Landa

Institute of Gastroenterology and Liver Disease

Barzilai University Medical Center

לל החולה החולה תיאורתיאור, , עולה וותיקה מברית המועצותעולה וותיקה מברית המועצות, , 33+ + נ נ , , 6464מדובר בחולה בת מדובר בחולה בת

: : בעלת רקע שלבעלת רקע של,,עקרת ביתעקרת בית קע,,עקעק קעע עקצרת סימפונותקצרת סימפונות

יתר יתרהשמנת תרהשמנת תרהשמנת השמנת דד""יתר ליתר ל

בשינה נשימה דום בשינהתסמונת נשימה דום נהתסמונת מה בש נהתסמונת דום נש מה בש תסמונת דום נש - - בב RCCRCCמצבה בתר כריתה חלקית של כליה ימנית בשל מצבה בתר כריתה חלקית של כליה ימנית בשל

20062006,IKAPRESS,DISOTHIAZIDE,IKAPRESS,DISOTHIAZIDE::נטילת תרופותנטילת תרופות

NORMOPRESSAN,SIMVACOR,FUSID,FORADILNORMOPRESSAN,SIMVACOR,FUSID,FORADIL , , ,, , ,Colon CaColon Caאו או IBD IBDללא רקע משפחתי של ללא רקע משפחתי של

תיאור קליני תיאור קליני לל

ל"" ל ל לל ל ל ל ::ל הופנתה אלינו באופן אמבולטורי בשלל הופנתה אלינו באופן אמבולטורי בשל""הנהנDyspepsiaDyspepsiaמזה כחצי שנהמזה כחצי שנה y p py p p

מאורע של שחרה בשבוע אחרון טרם קבלתה מאורע של שחרה בשבוע אחרון טרם קבלתה ל ללל ללא תמונה קלינית אחרתללא תמונה קלינית אחרתלל

IIIIתיאור קליני תיאור קליני IIIIלל

::בדיקה גופניתבדיקה גופניתתקינהתקינהתקין--בטןבטן תקיןניע רכהניע רכהבטן רגישותבטן רגישותללא ללא ןבטןבטן ע תק ןנ ע תק שות,,בטן רכהבטן רכה,,נ שותללא רג ללא רג

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8080: : דופקדופקצצ""ממ 3737: : חוםחום

IIIIIIלל IIIIIIתיאור קליניתיאור קליני

::בדיקות מעבדהבדיקות מעבדהקקאנמיה נורמוציטית קלהאנמיה נורמוציטית קלה::דד""סס

תקיניםתקינים ::אנזימי כבדאנזימי כבדתקיניםתקינים::אלקטרוליטיםאלקטרוליטים תקינים תקינים ::אלקטרוליטיםאלקטרוליטים

צואה לדם סמוי עם שיטה צואה לדם סמוי עם שיטה חיוביתחיובית--אימוניתאימונית

W k U G tW k U G tWork Up GastroscopyWork Up Gastroscopy

בקוטר בקוטר , , רירי מכוייב בקצהורירי מכוייב בקצהו--נצפה גידול תתנצפה גידול תת--מ ממוקד בעקומה הגדולה במ ממוקד בעקומה הגדולה ב""סס33--של כשל כ

AntrumAntrum

Bi iBi iBiopsiesBiopsies

High grade dysplasia focally seen inHigh grade dysplasia focally seen inHigh grade dysplasia focally seen in High grade dysplasia focally seen in overlying epitheliumoverlying epithelium

--CT CT לא הדגים לא הדגים . . ננ..בטן עם חבטן עם חממצאים פתולוגים בקיבהממצאים פתולוגים בקיבה

SS

II המשך המשךII

ממצא חוזרת ממצאגסטרוסקופיה חוזרת גסטרוסקופיה ה חוזרת ממצא ה חוזרת ממצא גסטרוסקופ גסטרוסקופללא שינוי עם תוצאות ללא שינוי עם תוצאות הביופסיות של הביופסיותדומות של ותדומות ופס ותדומות של הב ופס דומות של הב

DIFFERENTIALDIFFERENTIALDIFFERENTIALDIFFERENTIAL DIAGNOSIS ?DIAGNOSIS ?

ממאיר ממאיר GASTRICGASTRIC CANCERCANCERMETASTASISMETASTASISMETASTASISMETASTASISGISTGISTCarcinoidCarcinoidGlomus tumorGlomus tumorGlomus tumorGlomus tumorLymphomaLymphomaLeiomyosarcomaLeiomyosarcoma

רשפירשפיר רשפ שפLeiomyomaLeiomyomaPancreatic restPancreatic restLipomaLipomaLipomaLipomaNeural origin tumorNeural origin tumorDuplication cystDuplication cystGranular cell tumor Granular cell tumor Gastritis cystica profundaGastritis cystica profunda

IIII ……המשךהמשך II II

Gastroscopy with peeling or Gastroscopy with peeling or tunneled biopsiestunneled biopsiestunneled biopsies tunneled biopsies EUSEUS עם עם FNA FNA \\ Core biopsyCore biopsySurgerySurgery

ל נשלחה להמטופלת נשלחה SurgicalSurgical--המטופלת Surgical Surgicalהמטופלת נשלחה להמטופלת נשלחה לlaparoscopylaparoscopy

CysticallyCystically dilated glands in overlying epitheliumdilated glands in overlying epitheliumHerniated cystically dilated glands in submucosa linedHerniated cystically dilated glands in submucosa linedHerniated cystically dilated glands in submucosa lined Herniated cystically dilated glands in submucosa lined by bland epitheliumby bland epithelium

AA BB

Gastritis Cystica Profunda: Gastritis Cystica Profunda: A Rare Gastric Tumor A Rare Gastric Tumor Masquerading as aMasquerading as aMasquerading as a Masquerading as a MalignancyMalignancyMalignancy Malignancy

iiHistory History

Gastritis cystica profunda (GCP) has Gastritis cystica profunda (GCP) has b i f tl d ib d i thb i f tl d ib d i thbeen infrequently described in the been infrequently described in the literatureliteratureIn In 1981 1981 Franzin and Novelli coined the Franzin and Novelli coined the term term ““gastritis cystica profunda,gastritis cystica profunda,”” and and described described 15 15 cases of GCP that were cases of GCP that were initially confused with other gastric initially confused with other gastric pathologies such as mature erosions, pathologies such as mature erosions, gastric adenomas, Mgastric adenomas, Méénnéétriertrier’’s disease, s disease, gastric adenocarcinoma, hyperplastic gastric adenocarcinoma, hyperplastic polyps and other pathologies.polyps and other pathologies.

EPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGY

Mean age among women wasMean age among women wasMean age among women was Mean age among women was 5555..6 6 years (range, years (range, 39 39 -- 79 79 years)years)

Mean age among men was Mean age among men was 6262..2 2 years (range, years (range, 39 39 -- 81 81 years)years)

BACKGROUNDBACKGROUNDBACKGROUNDBACKGROUND

The most common anatomic GCPThe most common anatomic GCPThe most common anatomic GCP The most common anatomic GCP location was the gastric body (location was the gastric body (6262%) %) Fundus (Fundus (2424%)%)Fundus (Fundus (2424%)%)Antrum (Antrum (88%)%)Cardia (Cardia (66%); some lesions were at %); some lesions were at the junction of body and antrum.the junction of body and antrum.j yj y

Risk factors forRisk factors forRisk factors for Risk factors for GCPGCP

The majority of reported cases patients with a The majority of reported cases patients with a history of gastric surgery (history of gastric surgery (6565%) however as in%) however as inhistory of gastric surgery (history of gastric surgery (6565%), however, as in %), however, as in the current case, GCP has been described in the current case, GCP has been described in nonnon--operated patients as welloperated patients as wellnonnon operated patients as well operated patients as well Mucosal prolapse and duodenal reflux which Mucosal prolapse and duodenal reflux which may occur following gastric surgery are believed may occur following gastric surgery are believed y g g g yy g g g yto propagate the cystic changes observed within to propagate the cystic changes observed within the submucosa the submucosa In animal studies on rats, GCP was observed In animal studies on rats, GCP was observed following both Billroth I and Billroth II partial following both Billroth I and Billroth II partial gastrectomies although a significantly highergastrectomies although a significantly highergastrectomies, although a significantly higher gastrectomies, although a significantly higher incidence following a Billroth II procedure incidence following a Billroth II procedure

Cli i l if t tiCli i l if t tiClinical manifestationsClinical manifestations

Typically nonspecific, leading to Typically nonspecific, leading to significant diagnostic uncertaintysignificant diagnostic uncertaintysignificant diagnostic uncertaintysignificant diagnostic uncertainty

Abdominal pain was the mostAbdominal pain was the mostAbdominal pain was the most Abdominal pain was the most common presenting complaint common presenting complaint ((2727%)%)((2727%) %) Bleeding/anemia (Bleeding/anemia (1616%)%)Fullness (Fullness (88%)%)Fullness (Fullness (88%)%)Anorexia/weight loss (Anorexia/weight loss (88%)%)GCP was an incidental finding inGCP was an incidental finding inGCP was an incidental finding in GCP was an incidental finding in 1919% of patients.% of patients.

Joseph L. Laratta1, Tatiana N. Buhtoiarova2, Surgical Science, 2012, 3, 158-164

Di iDi iDiagnosisDiagnosis

GCP cannot be GCP cannot be diagnosed ondiagnosed ondiagnosed on diagnosed on endoscopic endoscopic evaluation aloneevaluation aloneGCP generallyGCP generallyGCP generally GCP generally lacks mucosal lacks mucosal erosion, ulceration, erosion, ulceration, marked fibrosis, ormarked fibrosis, ormarked fibrosis, or marked fibrosis, or firm consistency, firm consistency, which can occur which can occur with gastric with gastric ggadenocarcinoma adenocarcinoma and less commonly and less commonly with GISTwith GIST

EUS Di iEUS Di iEUS DiagnosisEUS Diagnosis

On EUS, GCP On EUS, GCP typically appears typically appears yp y ppyp y ppas a homogeneous, as a homogeneous, hypoechoic cystic hypoechoic cystic mass with minimalmass with minimalmass with minimal, mass with minimal, if any, solid if any, solid componentcomponent

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Radiographically, Radiographically, GIST and GCP both GIST and GCP both appear asappear asappear as appear as hypoechoic, hypoechoic, intramural intramural polypoid masses polypoid masses with cystic changeswith cystic changes

P th l i l Di iP th l i l Di iPathological DiagnosisPathological Diagnosis

(A) The EMR specimen of (A) The EMR specimen of posterior wall of lower body posterior wall of lower body

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p yp yshowed numerous tiny cysts lined showed numerous tiny cysts lined by flattened epithelium within the by flattened epithelium within the submucosa, consistent with submucosa, consistent with

i i i f d (i i i f d (

A

gastritis cystica profunda (H&E, gastritis cystica profunda (H&E, ××4040))(B) EMR specemien of anterior (B) EMR specemien of anterior wall of lower body. The cancer wall of lower body. The cancer cells focally infiltrated to the cells focally infiltrated to the superficial submucosal layer, and superficial submucosal layer, and

l i l li d b fl dl i l li d b fl d

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BBB

multiple cysts lined by flattened multiple cysts lined by flattened epithelium were present within epithelium were present within the submucosa, consistent with the submucosa, consistent with

t iti ti f d (H&Et iti ti f d (H&E

B

gastritis cystica profunda (H&E, gastritis cystica profunda (H&E, ××100100).).

Joseph L. Laratta1, Tatiana N. Buhtoiarova2, Surgical Science, 2012, 3, 158-164

II In summaryIn summary

GCP is a rare gastric submucosal GCP is a rare gastric submucosal tumor that is confused with othertumor that is confused with othertumor that is confused with other tumor that is confused with other more common gastric pathologiesmore common gastric pathologiesIt is important to consider GCP in the It is important to consider GCP in the differential diagnosis of patients differential diagnosis of patients g pg ppresenting with suspicious presenting with suspicious submucosal gastric lesionssubmucosal gastric lesionssubmucosal gastric lesions, submucosal gastric lesions, irrespective of nonirrespective of non--diagnostic EUSdiagnostic EUS--FNA biopsiesFNA biopsiesFNA biopsiesFNA biopsies