Letters to the editor
Figure 1. A and B, Endoscopic view of lesion before and after EMR. C, Melanosis coli and submucosal eosinophilic abscess containing the Anisakis nematode (H&E, orig. mag. 4). D, Anisakis simplex showing Y-shaped lateral cords and surrounded by eosinophils (H&E, orig. mag. 20).
features of the parasite (Y-shaped lateral cords) were consistent with Anisakis simplex (Fig. 1C and D). The results of serologic and other laboratory tests were within normal limits. At a guided interview later, she confirmed having eaten assiduously “boquerones en vinagre,” or raw anchovies (Engraulis encrasicolus) pickled in vinegar, a typical Mediterranean food. The patient has remained asymptomatic. This case depicts a rare presentation of colon anisakiasis in which endoscopic resection was both diagnostic and therapeutic. Anisakiasis is rarely located in the colon, with less than 1% in the reported medical literature among all cases of GI anisakiasis.2 More than half of these cases were on the right side of the colon. It is believed that the large distance to the colon is too far for the ingested larvae to travel. The clinical features in symptomatic patients are often similar to those of acute appendicitis, or intestinal occlusion simulating a tumor of the colon. Prior preventive measures or any suspicion of the invasion of larvae are important clues to be determined beforehand. Otherwise, colonoscopy may be used to diagnose and treat the cause, avoiding unnecessary surgery. Fausto Riu Pons, MD Department of Gastroenterology Javier Gimeno Beltran, MD Raquel Albero Gonzalez, MD Department of Pathology Marco Antonio Álvarez Gonzalez, MD, PhD www.giejournal.org
Josep M. Dedeu Cusco, MD, PhD Luis Barranco Priego, MD Agustín Seoane Urgorri, MD Department of Gastroenterology Hospital del Mar Barcelona, Spain REFERENCES 1. Van Thiel P, Kuipers FC, Roskam RT. A nematode parasitic to herring, causing acute abdominal syndromes in man. Trop Geogr Med 1960;12:97-113. 2. Mineta S, Shimanuki K, Sugiura A, et al. Chronic anisakiasis of the ascending colon associated with carcinoma. J Nippon Med Sch 2006;73:169-74. http://dx.doi.org/10.1016/j.gie.2014.10.017
Chasing zebras: large hyperplastic gastric polyp with inflammatory fibroid changes To the Editor: A 47-year-old Hispanic man had experienced epigastric pain for 2 years. A 1.7 cm mass was seen in the gastric body on abdominal CT (Fig. 1A). EGD revealed a 2-cm polyp near the incisura with a central nipple-like protrusion draining clear fluid (Fig. 1B). EUS showed a 2 1.5 cm lesion in the first and second sonographic layers with indistinct margins. The fourth sonographic layer was intact. The Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1051
Letters to the editor
Figure 1. A, Abdominal CT scan showing a 1.7-cm mass in the gastric body (arrow). B, Endoscopic view of the polyp with central nipple-like protrusion draining clear fluid. C, EUS view with labeled sonographic layers. D, Low-power overview of entire polyp, showing both hyperplastic and inflammatory elements (H&E, orig. mag. 1.1).
lesion demonstrated heterogeneous echogenicity with anechoic, hypoechoic, and hyperechoic foci (Fig. 1C). The polyp was resected. Histologic analysis showed elongation of glandular necks with focal areas of stromal proliferation consistent with a hyperplastic polyp with inflammatory fibroid changes (Fig. 1D). Hyperplastic gastric polyps are generally considered benign; however, they may contain adenomatous or carcinomatous epithelium.1 EUS findings of hyperplastic polyps have not been well described. Nagata et al1 described a case of hyperplastic polyp as thickening of the second layer with multiple minute cystic dilations. Inflammatory fibroid polyps (IFP) are nonneoplastic polyps that arise from the deep mucosa or submucosa and appear on EUS as homogenous hypoechoic lesions arising from the second or third layer of gastric wall.2 The mixed echogenicity of our polyp may have been due to varying degrees of vascularity within the polyp. The superficial layers appeared hyperechoic because of increased vascularity resulting from central ulceration and inflammation, whereas the parenchyma of polyp itself appeared hypoechoic. The anechoic area was predominantly a liquid-containing cystic area. Large mucosal-based polyps are not easily distinguishable from IFPs on endoscopic appearance. Central changes seen in our polyp have also been described in large IFPs. EUS can be used to distinguish these polyps based on their origin from different layers of the gastric wall. Definitive diagnosis, however, can be made only by histopathologic 1052 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
examination, warranting en bloc removal of all large gastric polyps. Hadi Bhurgri, MD Sami Samiullah, MD Department of Gastroenterology Kenneth M. Klein, M.D. Department of Pathology and Laboratory Medicine Sushil K. Ahlawat, MD Department of Medicine Gastroenterology Section Rutgers University – New Jersey Medical School Newark, New Jersey, USA REFERENCES 1. Nagata S, Tanaka S, Ito M, et al. Cardiac glands hyperplastic polyp of the stomach. J Gastroenterol Hepatol 2005;20:1461-3. 2. Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Endoscopic features of gastric inflammatory fibroid polyps. Am J Gastroenterol 1996;91:1595-8. http://dx.doi.org/10.1016/j.gie.2014.10.020
Endoscopic palliation of advanced cholangiocarcinoma: A need for a real trial! To the Editor: We read with interest the study by Strand et al1 comparing endoscopic radiofrequency ablation (RFA) www.giejournal.org
Figure 1. A and B, Endoscopic view of lesion before and after EMR. C, Melanosis coli and submucosal eosinophilic abscess containing the Anisakis nematode (H&E, orig. mag. 4). D, Anisakis simplex showing Y-shaped lateral cords and surrounded by eosinophils (H&E, orig. mag. 20).
features of the parasite (Y-shaped lateral cords) were consistent with Anisakis simplex (Fig. 1C and D). The results of serologic and other laboratory tests were within normal limits. At a guided interview later, she confirmed having eaten assiduously “boquerones en vinagre,” or raw anchovies (Engraulis encrasicolus) pickled in vinegar, a typical Mediterranean food. The patient has remained asymptomatic. This case depicts a rare presentation of colon anisakiasis in which endoscopic resection was both diagnostic and therapeutic. Anisakiasis is rarely located in the colon, with less than 1% in the reported medical literature among all cases of GI anisakiasis.2 More than half of these cases were on the right side of the colon. It is believed that the large distance to the colon is too far for the ingested larvae to travel. The clinical features in symptomatic patients are often similar to those of acute appendicitis, or intestinal occlusion simulating a tumor of the colon. Prior preventive measures or any suspicion of the invasion of larvae are important clues to be determined beforehand. Otherwise, colonoscopy may be used to diagnose and treat the cause, avoiding unnecessary surgery. Fausto Riu Pons, MD Department of Gastroenterology Javier Gimeno Beltran, MD Raquel Albero Gonzalez, MD Department of Pathology Marco Antonio Álvarez Gonzalez, MD, PhD www.giejournal.org
Josep M. Dedeu Cusco, MD, PhD Luis Barranco Priego, MD Agustín Seoane Urgorri, MD Department of Gastroenterology Hospital del Mar Barcelona, Spain REFERENCES 1. Van Thiel P, Kuipers FC, Roskam RT. A nematode parasitic to herring, causing acute abdominal syndromes in man. Trop Geogr Med 1960;12:97-113. 2. Mineta S, Shimanuki K, Sugiura A, et al. Chronic anisakiasis of the ascending colon associated with carcinoma. J Nippon Med Sch 2006;73:169-74. http://dx.doi.org/10.1016/j.gie.2014.10.017
Chasing zebras: large hyperplastic gastric polyp with inflammatory fibroid changes To the Editor: A 47-year-old Hispanic man had experienced epigastric pain for 2 years. A 1.7 cm mass was seen in the gastric body on abdominal CT (Fig. 1A). EGD revealed a 2-cm polyp near the incisura with a central nipple-like protrusion draining clear fluid (Fig. 1B). EUS showed a 2 1.5 cm lesion in the first and second sonographic layers with indistinct margins. The fourth sonographic layer was intact. The Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1051
Letters to the editor
Figure 1. A, Abdominal CT scan showing a 1.7-cm mass in the gastric body (arrow). B, Endoscopic view of the polyp with central nipple-like protrusion draining clear fluid. C, EUS view with labeled sonographic layers. D, Low-power overview of entire polyp, showing both hyperplastic and inflammatory elements (H&E, orig. mag. 1.1).
lesion demonstrated heterogeneous echogenicity with anechoic, hypoechoic, and hyperechoic foci (Fig. 1C). The polyp was resected. Histologic analysis showed elongation of glandular necks with focal areas of stromal proliferation consistent with a hyperplastic polyp with inflammatory fibroid changes (Fig. 1D). Hyperplastic gastric polyps are generally considered benign; however, they may contain adenomatous or carcinomatous epithelium.1 EUS findings of hyperplastic polyps have not been well described. Nagata et al1 described a case of hyperplastic polyp as thickening of the second layer with multiple minute cystic dilations. Inflammatory fibroid polyps (IFP) are nonneoplastic polyps that arise from the deep mucosa or submucosa and appear on EUS as homogenous hypoechoic lesions arising from the second or third layer of gastric wall.2 The mixed echogenicity of our polyp may have been due to varying degrees of vascularity within the polyp. The superficial layers appeared hyperechoic because of increased vascularity resulting from central ulceration and inflammation, whereas the parenchyma of polyp itself appeared hypoechoic. The anechoic area was predominantly a liquid-containing cystic area. Large mucosal-based polyps are not easily distinguishable from IFPs on endoscopic appearance. Central changes seen in our polyp have also been described in large IFPs. EUS can be used to distinguish these polyps based on their origin from different layers of the gastric wall. Definitive diagnosis, however, can be made only by histopathologic 1052 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
examination, warranting en bloc removal of all large gastric polyps. Hadi Bhurgri, MD Sami Samiullah, MD Department of Gastroenterology Kenneth M. Klein, M.D. Department of Pathology and Laboratory Medicine Sushil K. Ahlawat, MD Department of Medicine Gastroenterology Section Rutgers University – New Jersey Medical School Newark, New Jersey, USA REFERENCES 1. Nagata S, Tanaka S, Ito M, et al. Cardiac glands hyperplastic polyp of the stomach. J Gastroenterol Hepatol 2005;20:1461-3. 2. Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Endoscopic features of gastric inflammatory fibroid polyps. Am J Gastroenterol 1996;91:1595-8. http://dx.doi.org/10.1016/j.gie.2014.10.020
Endoscopic palliation of advanced cholangiocarcinoma: A need for a real trial! To the Editor: We read with interest the study by Strand et al1 comparing endoscopic radiofrequency ablation (RFA) www.giejournal.org
