해외 증례(Canada) Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection

관리자
2024-01-31
조회수 39

VideoGIE. 2023 Sep 14;9(1):1-3. doi: 10.1016/j.vgie.2023.09.003. eCollection 2024 Jan.


<CASE>

* 75-year-old woman 

* C/Cx: syncope, nausea, vomiting, and abdominal pain (Emergency department)

* P/I : Experiencing intermittent postprandial nausea and vomiting for several weeks. 

* CT scan of the abdomen and pelvis: gastric outlet obstruction secondary to gastrogastric intussusception from a 5-cm mass extending into the proximal duodenum (Figure 1)

Figure 1. Contrast-enhanced CT scan of the abdomen and pelvis. Axial images: A, Gastrogastric intussusception with the intussusceptum (dashed line) telescoping into the intussuscipiens (arrowheads). B, Lobulated mass (asterisk) serving as the lead point for the intussusception. Small-volume fluid (arrow) delineates the mass from the wall of the duodenum. Coronal images: C, Redemonstration of long-segment intussusception (dashed line) with lobulated mass (asterisk) serving as the lead point and extending into the proximal duodenum. D, Lobulated mass (asterisk) occupying and expanding the duodenal lumen.


* Upper endoscopy: the mass was observed prolapsing into the duodenum (Fig. 2A). However, with insufflation, the intussusception spontaneously resolved (Fig. 2B). The lesion seen along the greater curve of the proximal body had a Paris 1sp morphology. The background body mucosa displayed pan-atrophy, indicative of autoimmune atrophic gastritis.

* Radial EUS: second-layer lesion without evidence of muscularis propria involvement. 

* Endoscopic submucosal dissection (ESD)

  • 1.Oncologic: Gastric adenomatous lesions greater than 2 cm have significant risk of carcinoma. This lesion was 5 to 6 cm.
  • 2.Hemostatic: With ESD, much more precise cutting is possible, along with the ability to perform hemostasis on vessels. In contrast, EMR involves transecting a large area rapidly without much precision.
  • 3.Perforation risk: Considering that this lesion caused intussusception and was quite bulky, it was believed that EMR would be less safe. In some cases, areas thought to be pedunculated when snared can lead to significant perforations in EMR. However, with ESD’s higher precision, if an incorrect plane is noted and a small perforation occurs, it can be easily closed.
  • - 2-mm FlushKnife BTs (Fujifilm, Tokyo, Japan) and multipoint traction (Fig. 2C) 
  • - ERBE VIO 3 (Tübingen, Germany) was used with preciseSECT effect 4.0 and ENDO CUTI effect 2, duration 2, interval 2 
  • * Final pathology: pyloric gland adenoma with high-grade dysplasia that was completely excised (Fig. 2D).

Figure 2. A, Endoscopic image showing gastric wall intussusception with the adenoma protruding into the duodenum. B, Retroflexed view revealing the pyloric gland adenoma along the greater curve after reduction by air insufflation. C, Endoscopic submucosal dissection. D, Low-power view of the pyloric gland adenoma stained with hematoxylin phloxine saffron (orig. mag. ×100).

 

<Conclusions>

This case of gastrogastric intussusception, causing gastric outlet obstruction and acute pancreatitis secondary to a large pyloric gland adenoma, highlights several rare clinical entities. First, gastrogastric intussusception in adults is an exceptionally rare phenomenon, with only a few documented cases reported in the literature. Second, in the case of large gastric neoplasms causing intussusception, rarely the neoplasm may extend down into the duodenum and obstruct the ampulla of Vater causing acute pancreatitis. Furthermore, pyloric gland adenomas are rare gastric neoplasms that tend to be polypoid in morphology and are associated with autoimmune gastritis, predominantly occurring in female patients, as in this case. Lastly, the traditional management for lesions causing gastroduodenal intussusception is surgical because of the risk of malignancy. However, in this case, the patient underwent successful curative and therapeutic endoscopic resection with ESD.


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