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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 66-68

Endoscopic ultrasound of isolated gastric corrosive stricture mimicking linitis plastica


1 Departement of Gastroenterology and Hepatology, Mansoura Faculty of Medicine, Mansoura, Egypt
2 Department of Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt
3 Department of Pathology, Mansoura Faculty of Medicine, Mansoura, Egypt

Date of Submission01-Jul-2014
Date of Acceptance21-Jul-2014
Date of Web Publication13-Feb-2015

Correspondence Address:
Ahmed Youssef Altonbary
Departement of Gastroenterology and Hepatology, Mansoura Faculty of Medicine, Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.151365

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  Abstract 

Isolated gastric outlet obstruction after 1 month of asymptomatic ingestion of corrosive is a rare phenomenon and rarely reported. In this type of cases, diagnosis is very difficult due to no symptoms at the time of poisoning, and biased history. We report a case of a young male presented with isolated gastric outlet obstruction after 1 month of asymptomatic ingestion of toilet cleaner, which was known to us later, mimicking linitis plastica. On upper endoscopy, the stomach was grossly edematous, antrum edematous and inflamed with reduced distensibility and narrow pyloric canal. Endoscopic ultrasound of the stomach revealed diffuse thickening of the gastric wall, mainly the antrum, involving submucosa and muscularis propria. We propose corrosive injury to be in the differential diagnosis of gastric linitis plastica.

Keywords: Corrosive, endoscopic ultrasound, linitis plastica


How to cite this article:
Altonbary AY, Deiab AG, Negm EH, El Sorogy MM, Elkashef WF. Endoscopic ultrasound of isolated gastric corrosive stricture mimicking linitis plastica. Endosc Ultrasound 2015;4:66-8

How to cite this URL:
Altonbary AY, Deiab AG, Negm EH, El Sorogy MM, Elkashef WF. Endoscopic ultrasound of isolated gastric corrosive stricture mimicking linitis plastica. Endosc Ultrasound [serial online] 2015 [cited 2019 Sep 20];4:66-8. Available from: http://www.eusjournal.com/text.asp?2015/4/1/66/151365


  Introduction Top


Most of the time corrosive poisons cause severe local reactions then esophageal strictures and finally gastric injury. Rarely acid may cause only late complication like gastric injury. In this type of cases, diagnosis is very difficult due to no symptoms at the time of poisoning, and biased history. [1] The mode of tissue injury with acids is a process of coagulation necrosis. The coagulum prevents the corrosive agent from spreading transmurally and hence reduces the incidence of full thickness injury. [2] We report a case of isolated gastric outlet obstruction after 1 month of asymptomatic ingestion of toilet cleaner, which was known to us later, with full thickness injury mimicking linitis plastica.


  Case Report Top


A 35-year-old male presented with intractable vomiting of gradual onset and progressive course for the last 7 days. The frequency of stool passing and urination were reduced. No other history of fever, jaundice, epigastric pain, hematemesis, melena, or headache was reported. On examination, patient was conscious, lethargic, dry tongue, and afebrile. Heart rate was 130/min with all other vitals normal. All other systemic examinations revealed no abnormalities. Biochemical profile was unremarkable. On upper endoscopy, the stomach was grossly edematous, antrum edematous and inflamed with reduced distensibility and narrow pyloric canal. Multiple biopsies were taken and sent for histopathological examination, which revealed chronic non-specific inflammation. Endoscopic ultrasound (EUS) was done, which revealed diffuse thickening of the gastric wall up to 21 mm in the antrum [Figure 1] and 11.5 mm in the gastric body [Figure 2] involving submucosa and muscularis propria. Biopsies were repeated again with bite-on-bite technique and sent for histopathological examination which again revealed chronic nonspecific inflammation. After which, patient's father confess that there was a suicidal attempt 1 month ago with a toilet cleaner which passed without any symptoms or complications. The patient was referred for surgical evaluation. Exploration revealed marked thickening of the gastric wall of the distal stomach with marked luminal stenosis, however, the serosa was intact [Figure 3]. Subtotal gastrectomy was done, and the patient passed a smooth postoperative course. Postoperative pathological examination of the resected specimen showed gastric mucosa with focal erosions and submucosa with granulation tissue and dense inflammatory reaction [Figure 4] and [Figure 5].
Figure 1. Radial endoscopic ultrasound image showing diffuse thickening of the antral wall (21 mm) involving mainly the submucosa and muscularis propria

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Figure 2. Radial endoscopic ultrasound image showing diffuse thickening of the gastric body wall (11.5 mm) involving mainly the submucosa and muscularis propria

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Figure 3. The resected specimen is showing diffuse thickening of the gastric wall mainly the antrum and the pyloric canal

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Figure 4. Gastric mucosa with focal erosions and submucosa showing dense inflammatory reaction, H and E, ×200

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Figure 5. Ulcerated area with granulation tissue and dense inflammatory reaction, H and E, ×200

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  Discussion Top


The first corrosive induced antral stenosis was reported in 1828. [3] "Acid licks the esophagus and bites the stomach" was the dictum in the past. This principle has been challenged by many authors who have shown that even with acid ingestion esophageal injuries are common. [4] The magnitude of the injury depends upon several factors such as the nature of the caustic agent, volume ingested, concentration, duration of mucosal exposure, age of the patient and the intent (suicidal or accidental) with which the corrosive was consumed. [5] The largest Indian experience, reported 33% of 109 injuries with isolated gastric injury. The majority had prepyloric strictures (83.5%) while the remaining strictures were located in the antrum, body, pyloroduodenal area, or were diffuse. [6] The mode of tissue injury with acids is a process of coagulation necrosis. The coagulum prevents the corrosive agent from spreading transmurally and hence reduces the incidence of full thickness injury. [2] Diffuse gastrointestinal (GI) wall thickening is predominantly observed in the stomach and less frequently, in the esophagus and rectum. Malignant causes include linitis plastica and less frequently, lymphoma or diffuse metastasis. Benign causes are multiple, including eosinophilic infiltration, Zollinger-Ellison syndrome, Ménétrier's disease, and amyloidosis. [7] In subepithelial infiltrating tumors, standard endoscopic biopsy sampling often yields false negative results, and the diagnostic yield of bite-on-bite biopsy sampling is unknown, although this technique is commonly used. [8] At least in the stomach, EUS without sampling is relatively accurate in discriminating malignant from benign conditions: In a prospective study of 61 patients, the thickening of the submucosa and/or muscularis propria (as opposed to thickening limited to the mucosa) was the single independent predictor of malignancy; the clinical impact of this feature was high because the probability of malignancy was 95% versus 5%, respectively, depending on whether deep wall layers were thickened or not. [9] In a prospective study, the diagnostic accuracy of EUS-fine needle aspiration was significantly lower for diffuse GI wall thickening as compared with all other indications. [10] In this patient, there was thickening of the submucosa and muscularis propria although it is a benign lesion. We propose corrosive injury to be in the differential diagnosis of gastric linitis plastica.

 
  References Top

1.
Mishra S, Swain B. Gastric outlet obstruction due to isolated pyloric stenosis following corrosive acid ingestion: A case report. J Med Sci Clin Res 2014;2:723-6.  Back to cited text no. 1
    
2.
Lakshmi CP, Vijayahari R, Kate V, et al. A hospital-based epidemiological study of corrosive alimentary injuries with particular reference to the Indian experience. Natl Med J India 2013;26:31-6.  Back to cited text no. 2
    
3.
Gray HK, Holmes CL. Pyloric stenosis caused by ingestion of corrosive substances; report of case. Surg Clin North Am 1948;28:1041-56.  Back to cited text no. 3
[PUBMED]    
4.
Lahoti D, Broor SL. Corrosive injury to the upper gastrointestinal tract. Indian J Gastroenterol 1993;12:135-41.  Back to cited text no. 4
    
5.
Mattos GM, Lopes DD, Mamede RC, et al. Effects of time of contact and concentration of caustic agent on generation of injuries. Laryngoscope 2006;116:456-60.  Back to cited text no. 5
    
6.
Ananthakrishnan N, Parthasarathy G, Kate V. Chronic corrosive injuries of the stomach - A single unit experience of 109 patients over thirty years. World J Surg 2010;34:758-64.  Back to cited text no. 6
    
7.
Reeder MM, Olmsted WW, Cooper PH. Large gastric folds, local or widespread. JAMA 1974;230:273-4.  Back to cited text no. 7
[PUBMED]    
8.
Chambers LA, Clark WE 2 nd . The endoscopic diagnosis of gastroesophageal malignancy. A cytologic review. Acta Cytol 1986;30:110-4.  Back to cited text no. 8
    
9.
Ginès A, Pellise M, Fernández-Esparrach G, et al. Endoscopic ultrasonography in patients with large gastric folds at endoscopy and biopsies negative for malignancy: Predictors of malignant disease and clinical impact. Am J Gastroenterol 2006;101:64-9.  Back to cited text no. 9
    
10.
Pellisé Urquiza M, Fernández-Esparrach G, Solé M, et al. Endoscopic ultrasound-guided fine needle aspiration: Predictive factors of accurate diagnosis and cost-minimization analysis of on-site pathologist. Gastroenterol Hepatol 2007;30:319-24.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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