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Diagnostic Dilemma

Diagnostic Dilemma

This endoscopic photograph was obtained during an
upper-gastrointestinal endoscopy on a 60-year-old gentleman with epigastric
abdominal pain and melena. The photograph was taken in the stomach.

  1. The photograph reveals:
    a. A gastric bezoar
    b.
    A gastric polyp
    c. A large ulcer
    d. A mass
  2. At the time of endoscopy, the following should be considered:
    a. An attempt at endoscopic removal
    b. Laser therapy
    c. Cauterization
    d. Biopsy
    e. Brushings

The correct answer to question 1 is c. The endoscopic photograph reveals a large
ulcer located in the distal body of the stomach. Friability accounts for the
patient’s gastrointestinal bleeding. The margins of the ulcer are
irregular and heaped up, which should raise a suspicion of malignancy. There
are no exophytic masses or polypoid lesions present.

Bezoars are foreign bodies that are most commonly composed of vegetable
matter or hair. They usually occur in a setting of poor gastric emptying. No
bezoars were noted in this patient.

The correct answers are c, d, and e. Most gastric ulcers are
benign, but they require biopsy and follow-up. In this patient, the ulcer
has a suspicious endoscopic appearance. Therefore, multiple biopsies are
indicated. Sampling for cytologic analysis by brushing the ulcer and its
margins is also a standard technique.

Friability was evident, and bleeding occurred readily with biopsy and
brushing of the lesion. Hemostasis was accomplished by utilizing a
multipolar cautery probe. Other ways to treat bleeding include injection and
heater-probe application at the sites of bleeding. Laser therapy is usually
reserved for inoperable lesions.

There is increasing interest in endoscopic treatment of malignant and
premalignant gastrointestinal lesions. Snare removal and ablation of lesions
appear to have a role in the treatment of early lesions restricted to the
mucosa.

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