CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors

Postgastrectomy Lesion: A Rare Cause of Upper Gastrointestinal Bleeding Shenq-Jie Wong,1,2 Ping-Hsin Hsieh,3 and Hsiu-Po Wang1 1

Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei; 2Division of Gastroenterology and Hepatology, Department of Internal Medicine, En Chu Kong Hospital, New Taipei City; and 3Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chimei Medical Center, Tainan, Taiwan

Question: A 70-year-old man presented to the emergency department with tarry stool. His past history was notable for subtotal gastrectomy owing to peptic ulcer bleeding about 40 years ago. The hemoglobin dropped from a baseline of 12 to 10 g/dL. He denied recent nonsteroidal anti-inflammatory drug and antiplatelet agent use. Mild epigastric discomfort without radiation and no weight loss were noted. Esophagogastroduodenoscopy showed a 3-cm, subepithelial tumor with a small central ulceration, located at the gastric side, immediately adjacent to the anastomosis (Figure A). What is the diagnosis? Look on page 973 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.06.004

Gastroenterology 2014;147:972–973

CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 972): Gastric Cystica Profunda

Endoscopic ultrasonography was performed for further evaluation of the gastric subepithelial lesion. It showed a hypoechoic mass with multiple small cystic components (*) in lamina propria and submucosal layer (Figure B). Tunnel biopsy revealed elongated foveolae and cystically dilated glands within the submucosa, consistent with gastritis cystica profunda (GCP; Figure C). No treatment was done during the endoscopy owing to spontaneous hemostasis and refusal of endoscopic treatment by the patient. GCP is a rare, subepithelial lesion that causes bleeding. There are only 4 reported cases of hemorrhage from GCP in the medical literature.1 It is associated with previous gastric surgery and locates at gastroenterostomy site.2 It may be caused by chronic inflammation, ischemia, and presence of a foreign body. GCP seldom gives rise to clinical symptoms, but may present as abdominal pain, bloating, gastric obstruction, bleeding, and mucosal ulceration.2 The diagnosis of GCP is challenging, because it may present as a subepithelial tumor or solitary, diffuse polyps, or a giant gastric mucosal fold.3 Endoscopic ultrasonography provides a clear picture in differential diagnosis. Preoperative diagnosis is important, because it can prevent unnecessary extensive resections.

References 1. 2. 3.

Itte V, Mallick IH, Moore PJ. Massive gastrointestinal haemorrhage due to gastritis cystica profunda. Cases J 2008;1:85. Griffel B, Engleberg M, Reiss R, et al. Multiple polypoid cystic gastritis in old gastroenteric stoma. Arch Pathol 1974; 97:316–318. Okada M, Iizuka Y, Oh K, et al. Gastritis cystica profunda presenting as giant gastric mucosal folds: the role of endoscopic ultrasonography and mucosectomy in the diagnostic work-up. Gastrointest Endosc 1994;40:640–644.

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