Gastrenterology, Centro Hospitalar e Universitário de Coimbra, Portugal.
Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Portugal.
Rev Esp Enferm Dig. 2021 Sep;113(9):678-679. doi: 10.17235/reed.2021.7820/2021.
We present the case of a 69-year-old female undergoing esophagogastroduodenoscopy for iron-deficiency anemia investigation. She reported intermittent bloating, nausea and vomiting. A pedunculated polyp was identified arising from the greater curvature of the middle gastric body, with a long fibroelastic stalk (30mm) and a 60mm congestive head that prolapsed towards the pyloric ring, causing a complete gastric outlet obstruction (GOO). An en-block polypectomy was performed. An intraprocedural oozing bleeding from a large visible vessel at the residual stalk was managed using endoloop®. Histo-immunohistochemistry showed a R0-resection of a mixed-type gastric pyloric gland adenoma (PGA) positive for MUC-5AC and MUC-6 mucins, in a surrounding H. pylori-negative non-atrophic chronic gastritis. She became asymptomatic with anemia resolution. Adenomas account for up to 10% of gastric polyps. Histologically, they are categorized into intestinal, foveolar, pyloric and oxyntic types (1). PGA is a rare subtype, accounting for less than 3% of all gastric polyps (2). PGAs are usually solitary at gastric body, and occur in association with autoimmune gastritis, H. pylori and chemical gastritis (2). A normal background gastric mucosa has also been described (35.8%) (3). PGAs are devoid of apical mucin cap and label by both MUC-5AC and MUC-6 (2). Choi et al. (3) defined three PGA immunohistochemical phenotypes: pure pyloric-type (25.4%), with strong MUC-6 expression; predominant foveolar-type (3%), with MUC-5AC diffuse expression but ≤10% of MUC-6 expression and no foveolar differentiation; and mixed-type (61.2%), with variable MUC-5AC/MUC-6 expression. Most PGAs are asymptomatic, but clinically significant because of their potential for malignant transformation (12-47%) and complications, including gastrointestinal bleeding and obstruction (1, 3). GOO is rare, causing intermittent symptoms by polyp intussusception (ball-valve-syndrome) (4, 5). PGA management is challenging, depending on size, morphology and location. This case illustrates a successful endoscopic resection as a minimally invasive procedure of a doubly complicated PGA.
我们报告了一例 69 岁女性因缺铁性贫血接受食管胃十二指肠镜检查的病例。她报告间歇性腹胀、恶心和呕吐。在胃体中较大的曲率处发现了一个有蒂息肉，具有长的纤维弹性茎（30mm）和一个 60mm 的充血头部，向幽门环突出，导致完全性胃出口梗阻（GOO）。进行了整块息肉切除术。在残留茎上的一个大可见血管处发生术中渗血，使用内镜套扎环®进行处理。组织学-免疫组织化学显示混合性胃幽门腺腺瘤（PGA）的 R0 切除，MUC-5AC 和 MUC-6 粘蛋白阳性，周围为 H. pylori 阴性非萎缩性慢性胃炎。贫血得到纠正后，她无症状。腺瘤占胃息肉的 10%。组织学上，它们分为肠型、陷窝型、幽门型和胃底型（1）。PGA 是一种罕见的亚型，占所有胃息肉的不到 3%（2）。PGA 通常在胃体中为单发，与自身免疫性胃炎、H. pylori 和化学性胃炎相关（2）。也有描述正常的胃黏膜背景（35.8%）（3）。PGA 缺乏顶端粘蛋白帽，对 MUC-5AC 和 MUC-6 均有标记（2）。Choi 等人（3）定义了三种 PGA 免疫组织化学表型：纯幽门型（25.4%），MUC-6 表达强烈；主要为陷窝型（3%），MUC-5AC 弥漫表达，但 MUC-6 表达≤10%，无陷窝分化；混合型（61.2%），MUC-5AC/MUC-6 表达可变。大多数 PGA 无症状，但因其恶性转化（12-47%）和并发症的潜在风险而具有临床意义，包括胃肠道出血和梗阻（1,3）。GOO 很少见，息肉套叠（瓣阀综合征）导致间歇性症状（4,5）。PGA 的管理具有挑战性，取决于大小、形态和位置。本例说明了一种成功的内镜切除术作为一种微创治疗双重复杂 PGA 的方法。
