608
Letters, Techniques and Images
b
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Figure 1 (a) Radiography and (b) computed tomography of the chest indicates left pneumothorax (red arrows) and pleural effusion. (c) Esophagoscopy reveals a longitudinal cratered ulcer with a perforation on the lower esophagus. Yellow arrow indicates the perforated hole. a
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Digestive Endoscopy 2014; 26: 603–609
On day 31 post-stenting, the pneumothorax had resolved and the drainage from the left thoracic cavity had almost disappeared; hence, we removed the stent using an endoscope. Immediately after the stent was removed, esophagography revealed no leakage of contrast medium from the esophagus (Fig. 2a). The esophageal perforation had been closed by the surrounding epithelium (Fig. 2b). Subsequently, the patient resumed consumption of solid food, and his course was uneventful. In the present case, because the inflammation did not reach most parts of the mediastinum, we temporarily inserted a covered SEMS closing the esophageal perforation, and treated the left pyothorax through drainage. The methods of treatment for this condition vary according to the level of severity of the rupture and the complications present, and include conservative treatment, endoscopic stenting, and surgical treatment. However, the treatment policy also varies in each situation.1,2 At present, as a result of the marked developments in medical technology and endoscopic devices, conservative treatment for this condition is believed to be possible in more broad situations. Authors declare no conflict of interests for this article. Kazuhiro Ota, Toshihisa Takeuchi and Kazuhide Higuchi Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan doi: 10.1111/den.12310
REFERENCES 1 Schweigert M, Beattie R, Solymosi N et al. Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): An international study comparing the outcome. Am. Surg. 2013; 79: 634–40. 2 Gubler C, Bauerfeind P. Self-expandable stents for benign esophageal leakages and perforations: Long-term single-center experience. Scand. J. Gastroenterol. 2014; 49: 23–9.
Figure 2 (a) Esophagography immediately after the stent was removed reveals that contrast medium did not leak from the esophagus. (b) Esophagoscopy after removing the stent reveals that the esophageal perforation had become closed by the surrounding epithelium.
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pleural effusion that smelled of gastric acid. The pneumothorax did not improve despite thoracic aspiration and therefore it was necessary to quickly close the perforation. The esophageal perforation was closed through the insertion of a covered self-expandable metal stent (covered SEMS; diameter 22 mm, length 100 mm; CHOOSTENT® Esophagus Valve [CCC]; M.I. Tech, Seoul, Korea).
Magnifying narrow band imaging of pyloric gland adenoma in a patient with familial adenomatous polyposis Gastric fundic gland polyps (FGP) are the most frequent type of gastric lesions observed in familial adenomatous polyposis (FAP). However, gastric neoplasms have often been reported in patients with FAP.1 A 37-year-old woman with FAP was admitted to Ishikawa Prefectural Central Hospital for further investigation of gastric lesions. Endoscopy revealed a 20-mm polypoid lesion on the greater curvature of the upper body (Fig. 1a). This lesion was pale colored with translucency, and multiple FGP were seen in the non-atrophic mucosa. Examination with magnifying narrow band imaging (M-NBI) revealed a clear demarcation line (DL) (Fig. 1b).
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26: 603–609
Letters, Techniques and Images 609
The lesions were assessed according to the vessel plus surface classification system (VSCS) proposed by Yao et al.2,3 Regular microvascular (MV) and microsurface (MS) patterns were recognized in most of the polypoid lesion. The intervening parts (IP) enclosed by the marginal crypt epithelium (MCE) were uniform in size with regular morphology. These findings were similar to those of mucosa found in pyloric glands. However, an irregular MV pattern was recognized in several enlarged IP (Fig. 1c), and the edge of the MCE was slightly serrated in this area (Fig. 1d). Therefore, the VSCS determination was ‘irregular MV pattern plus irregular MS pattern with a DL’. Our initial diagnosis of this lesion was a carcinoma derived from a pyloric gland adenoma (PGA), and we carried out endoscopic mucosal
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d
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Figure 2 Histological findings. (a) (Low-power field), (b) (highpower field) hematoxylin-eosin staining shows dilated glands with dysplasia. The surface was covered by a layer of flat or papillary foveolar epithelium. (c) Positive staining for MUC6 in the deep layer of the epithelium.
resection. Histological examination showed dilated glands with dysplasia (Fig. 2a,b), and we ultimately diagnosed a PGA because of the diffuse expression of MUC6 (Fig. 2c). Our diagnosis using M-NBI was an adenocarcinoma because of the enlarged IP with MV outgrowth and the serrated edge of the MCE. PGA may present findings suggestive of adenocarcinoma by M-NBI and may resemble pyloric glands in their characteristics. These qualities may be useful when detecting dysplasia from multiple FGP in patients with FAP.
Acknowledgments The authors thank Dr Hideki Ishikawa (Graduate School of Medical Science, Kyoto Prefectural University of Medicine) and Dr Shingo Ishiguro (PCL Japan Inc.). Authors declare no conflict of interests for this article. Figure 1 Endoscopy findings. (a) Conventional endoscopy findings. Upper endoscopy revealed a 20-mm polypoid lesion on the greater curvature in the anterior wall of the upper gastric body. The lesion was pale colored with translucency (red arrowheads). Multiple fundic gland polyps were seen in the non-atrophic gastric mucosa. (b) Magnifying narrow band imaging findings (low magnification). We observed normal gastric mucosa, fundic gland polyps (FGP), and the main polypoid lesion. The demarcation line (blue arrows) between this lesion and the adjacent FGP was clear. (c) Magnifying narrow band imaging findings (maximal magnification). An irregular microvascular (MV) pattern was recognized in the enlarged intervening parts (red arrows). Regular MV and microsurface patterns that were similar to those of pyloric gland mucosa were recognized in most of this lesion. (d) Magnifying narrow band imaging findings (maximal magnification). The edge of the marginal crypt epithelium was slightly serrated (yellow arrows).
Shino Tsubokawa, Kei Tominaga and Hisashi Doyama Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan doi: 10.1111/den.12311
REFERENCES 1 Takeda A, Ban S, Tabuchi S, Aikawa K, Shinozuka N, Koyama I. Gastric lesions in familial adenomatous polyposis coli and gastric carcinogenesis. J. Fam. Tumor 2007; 7: 30–5. 2 Yao K, Anagnostopoulos GK, Ragunath K. Magnifying endoscopy for diagnosing and delineating early gastric cancer. Endoscopy 2009; 41: 462–7. 3 Yao K, Nagahama T, Matsui T, Iwashita A. Detection and characterization of early gastric cancer for curative endoscopic submucosal dissection. Dig. Endosc. 2013; 25: 44–54.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Letters, Techniques and Images
b
a
c
Figure 1 (a) Radiography and (b) computed tomography of the chest indicates left pneumothorax (red arrows) and pleural effusion. (c) Esophagoscopy reveals a longitudinal cratered ulcer with a perforation on the lower esophagus. Yellow arrow indicates the perforated hole. a
b
Digestive Endoscopy 2014; 26: 603–609
On day 31 post-stenting, the pneumothorax had resolved and the drainage from the left thoracic cavity had almost disappeared; hence, we removed the stent using an endoscope. Immediately after the stent was removed, esophagography revealed no leakage of contrast medium from the esophagus (Fig. 2a). The esophageal perforation had been closed by the surrounding epithelium (Fig. 2b). Subsequently, the patient resumed consumption of solid food, and his course was uneventful. In the present case, because the inflammation did not reach most parts of the mediastinum, we temporarily inserted a covered SEMS closing the esophageal perforation, and treated the left pyothorax through drainage. The methods of treatment for this condition vary according to the level of severity of the rupture and the complications present, and include conservative treatment, endoscopic stenting, and surgical treatment. However, the treatment policy also varies in each situation.1,2 At present, as a result of the marked developments in medical technology and endoscopic devices, conservative treatment for this condition is believed to be possible in more broad situations. Authors declare no conflict of interests for this article. Kazuhiro Ota, Toshihisa Takeuchi and Kazuhide Higuchi Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan doi: 10.1111/den.12310
REFERENCES 1 Schweigert M, Beattie R, Solymosi N et al. Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): An international study comparing the outcome. Am. Surg. 2013; 79: 634–40. 2 Gubler C, Bauerfeind P. Self-expandable stents for benign esophageal leakages and perforations: Long-term single-center experience. Scand. J. Gastroenterol. 2014; 49: 23–9.
Figure 2 (a) Esophagography immediately after the stent was removed reveals that contrast medium did not leak from the esophagus. (b) Esophagoscopy after removing the stent reveals that the esophageal perforation had become closed by the surrounding epithelium.
bs_bs_banner
pleural effusion that smelled of gastric acid. The pneumothorax did not improve despite thoracic aspiration and therefore it was necessary to quickly close the perforation. The esophageal perforation was closed through the insertion of a covered self-expandable metal stent (covered SEMS; diameter 22 mm, length 100 mm; CHOOSTENT® Esophagus Valve [CCC]; M.I. Tech, Seoul, Korea).
Magnifying narrow band imaging of pyloric gland adenoma in a patient with familial adenomatous polyposis Gastric fundic gland polyps (FGP) are the most frequent type of gastric lesions observed in familial adenomatous polyposis (FAP). However, gastric neoplasms have often been reported in patients with FAP.1 A 37-year-old woman with FAP was admitted to Ishikawa Prefectural Central Hospital for further investigation of gastric lesions. Endoscopy revealed a 20-mm polypoid lesion on the greater curvature of the upper body (Fig. 1a). This lesion was pale colored with translucency, and multiple FGP were seen in the non-atrophic mucosa. Examination with magnifying narrow band imaging (M-NBI) revealed a clear demarcation line (DL) (Fig. 1b).
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26: 603–609
Letters, Techniques and Images 609
The lesions were assessed according to the vessel plus surface classification system (VSCS) proposed by Yao et al.2,3 Regular microvascular (MV) and microsurface (MS) patterns were recognized in most of the polypoid lesion. The intervening parts (IP) enclosed by the marginal crypt epithelium (MCE) were uniform in size with regular morphology. These findings were similar to those of mucosa found in pyloric glands. However, an irregular MV pattern was recognized in several enlarged IP (Fig. 1c), and the edge of the MCE was slightly serrated in this area (Fig. 1d). Therefore, the VSCS determination was ‘irregular MV pattern plus irregular MS pattern with a DL’. Our initial diagnosis of this lesion was a carcinoma derived from a pyloric gland adenoma (PGA), and we carried out endoscopic mucosal
a
b
c
d
b
a
c
Figure 2 Histological findings. (a) (Low-power field), (b) (highpower field) hematoxylin-eosin staining shows dilated glands with dysplasia. The surface was covered by a layer of flat or papillary foveolar epithelium. (c) Positive staining for MUC6 in the deep layer of the epithelium.
resection. Histological examination showed dilated glands with dysplasia (Fig. 2a,b), and we ultimately diagnosed a PGA because of the diffuse expression of MUC6 (Fig. 2c). Our diagnosis using M-NBI was an adenocarcinoma because of the enlarged IP with MV outgrowth and the serrated edge of the MCE. PGA may present findings suggestive of adenocarcinoma by M-NBI and may resemble pyloric glands in their characteristics. These qualities may be useful when detecting dysplasia from multiple FGP in patients with FAP.
Acknowledgments The authors thank Dr Hideki Ishikawa (Graduate School of Medical Science, Kyoto Prefectural University of Medicine) and Dr Shingo Ishiguro (PCL Japan Inc.). Authors declare no conflict of interests for this article. Figure 1 Endoscopy findings. (a) Conventional endoscopy findings. Upper endoscopy revealed a 20-mm polypoid lesion on the greater curvature in the anterior wall of the upper gastric body. The lesion was pale colored with translucency (red arrowheads). Multiple fundic gland polyps were seen in the non-atrophic gastric mucosa. (b) Magnifying narrow band imaging findings (low magnification). We observed normal gastric mucosa, fundic gland polyps (FGP), and the main polypoid lesion. The demarcation line (blue arrows) between this lesion and the adjacent FGP was clear. (c) Magnifying narrow band imaging findings (maximal magnification). An irregular microvascular (MV) pattern was recognized in the enlarged intervening parts (red arrows). Regular MV and microsurface patterns that were similar to those of pyloric gland mucosa were recognized in most of this lesion. (d) Magnifying narrow band imaging findings (maximal magnification). The edge of the marginal crypt epithelium was slightly serrated (yellow arrows).
Shino Tsubokawa, Kei Tominaga and Hisashi Doyama Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan doi: 10.1111/den.12311
REFERENCES 1 Takeda A, Ban S, Tabuchi S, Aikawa K, Shinozuka N, Koyama I. Gastric lesions in familial adenomatous polyposis coli and gastric carcinogenesis. J. Fam. Tumor 2007; 7: 30–5. 2 Yao K, Anagnostopoulos GK, Ragunath K. Magnifying endoscopy for diagnosing and delineating early gastric cancer. Endoscopy 2009; 41: 462–7. 3 Yao K, Nagahama T, Matsui T, Iwashita A. Detection and characterization of early gastric cancer for curative endoscopic submucosal dissection. Dig. Endosc. 2013; 25: 44–54.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
