2023년 5월 Journal of International Medical Research 에 실린 case report 입니다. Hyperplastic polyp 발생은 H. pylori 에 의한 Type B gastritis도 있지만 AIG에 의한 Type A gastritis의 보다 size가 크고, multiple 이며 malignancy potency 가 큰 것으로 알려져 있습니다. AIG 환자에서 발생한 다발성 hyperplastic polyps (hamartomatous polyps 포함) 에 대한 증례 보고가 있어 정리해 보았습니다.
Figure 1. Images of endoscopy, endoscopic ultrasound, and histology of the submucosal tumor in the fundus. (a) Esophagogastroduodenoscopy showed a gastric submucosal tumor with a reddish area on the top in the fundus. (b) Endoscopic ultrasound (radial scan, 10 MHz) revealed the submucosal tumor as a heterogeneous tumor with multiple small hypoechoic or anechoic areas (yellow arrows). (c) Endoscopic ultrasound (radial scan, 10 MHz) revealed a hyperechoic calcified area with acoustic shadow (red arrow). (d) Operative specimen. The tumor (20 mm in diameter) was completely resected. (e) Low-power view illustrated the inverted growth lesion, which was almost covered by normal gastric mucosa, resulting in a submucosal tumor. The lesion consisted of dilated glands in various sizes and shapes and fibroblast cells in the submucosa. (f) Medium-power magnification demonstrated foveolar and pseudopyloric or mucous-neck glands without cytological atypia and partial cystic dilation and the infiltration of inflammatory cells that were scattered in the stroma. (g) Medium-power magnification demonstrated that the submucosal glands or cystic elements were connected with the overlying gastric mucosa through a defect of the muscularis mucosa (blue arrows). (h) Medium-power magnification demonstrated a marked reduction of oxyntic glands and pseudopyloric and intestinal metaplasia in the oxyntic mucosa. (i) The foveolar epithelium of normal mucosa on the surface and foveolar type glands in the submucosal lesion were positive for the mucin-5AC immunohistochemical stain. (j) Immunohistochemical stain for mucin 6 showed positive glands in both the normal mucosa and the submucosal lesion. (k) A few propria gland cells were positive in the normal mucosa and no positive cells were observed in the submucosal lesion with Pep-I immunohistochemical stain. (l) CgA immunohistochemical stain highlights linear and nodular enterochromaffin-like cell hyperplasia and (m) Three calcification lumps within considerably dilated glands in the specimen.
Figure 2. Endoscopic and histological images of pedunculated polyps in the body. (a, b) The esophagogastroduodenoscopy showed two markedly reddish pedunculated polyps in the posterior and anterior walls of the upper-middle body, with markedly atrophic manifestation in the oxyntic mucosa and a considerable amount of mucus attached and (c) Low-power view illustrated that the lesion consisted of irregularly shaped, haphazardly dilated hyperplastic foveola with pseudopyloric or mucous-neck glands in a background of edematous, inflamed stroma, and small, haphazardly distributed smooth muscle bundles in the mucosal layer.
Table 1. Major laboratory findings.
Like hyperplastic polyps, GHIPs may be a type of gastric mucosal proliferative disease. However, GHIPs are heterotopic in the submucosa through the defect of the muscularis mucosa. We highlight the importance of considering GHIPs as a differential diagnosis for SMTs in patients with AIG.
We report an unusual case of autoimmune gastritis (AIG) complicated with a submucosal tumor (SMT) and two pedunculated polyps in a 60-year-old man. The patient was admitted for epigastric distention, heartburn, and anorexia. Endoscopy showed an SMT in the fundus, two pedunculated polyps in the body, and markedly atrophic mucosa of the body and fundus. The SMT, measuring 20 mm in diameter, was resected by endoscopic submucosal dissection and histologically diagnosed as a gastric hamartomatous inverted polyp (GHIP), which is characterized by submucosal glandular proliferation, cystic dilatation, and calcification. The gland structures consisted of foveolar cells and pseudopyloric or mucous-neck cell types. The two pedunculated polyps that were resected by endoscopic mucosal resection were histologically diagnosed as hyperplastic polyps, which are characterized by hyperplastic foveolar glands with pseudopyloric or mucous-neck glands in the inflamed stroma in the mucosa, which consisted of almost the same types of lining cells as the GHIP in the fundus. Findings may indicate the relationship between GHIP, hyperplastic polyp, and AIG. We highlight considering GHIP as a differential diagnosis for an SMT in patients with AIG.
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