Clinical Case Summary

Case: We present a case of parietal cell carcinoma presenting with melena and pain abdomen. A 57-year-old Indian male, known diabetic and reformed smoker/alcoholic presented with upper abdominal pain and generalised weakness for three months. He also reported passage of black tarry stools for 3–4 days, about 15 days back, following which he started having general weakness and easy fatigability. Physical examination showed pallor with normal abdominal examination. Investigations revealed haemoglobin to be 10 g/dl and peripheral blood film showed microcytic hypochromic anaemia. Liver and renal function test were normal. Contrast enhanced CT scan of abdomen revealed arterial phase enhancing polypoidal lesion on greater curvature of the stomach. Esophagogastroduodenoscopy showed a six cm size ulcerated, friable mass in proximal body of stomach. Biopsies showed evidence of parietal cell carcinoma. The cells showed glandular arrangement, abundant granular eosinophilic cytoplasm, along with positive immunohistochemistry for Pan-Cytokeratin. Patient underwent exploratory laparotomy with total gastrectomy, distal pancreatectomy, splenectomy, roux-en-y esophagojejunostomy. He received adjuvant chemoradiotherapy. Patient recovered well and became asymptomatic.
Discussion: Parietal Cell Carcinoma is a rare malignant tumor of stomach with a strikingly male (9:1) preponderance. It generally occurs in older males and runs a relatively indolent course. These well to moderately differentiated tumors are usually diagnosed by pathology. Lymph node and distant metastasis occur rarely, hence prognosis is generally favourable.
Conclusion: Parietal cell carcinoma is rare cause of gastric mass and upper gastrointestinal bleeding. It is rarely considered in differential diagnosis clinically and diagnosis invariable emerges on histopathology.

References

Motta, M., Athanazio, D., Motta, A., Studart, E. and Athanazio, P., 2008. Parietal Cell (Oncocytic) Adenocarcinoma of the Stomach in a Female Patient: Superficial Spreading and Extensive Nodal Involvement. International Journal of Surgical Pathology, 16(4), pp.447-449.
Byrne, D., Holley, M. and Cuschieri, A., 1988. Parietal cell carcinoma of the stomach: association with long-term survival after curative resection. British Journal of Cancer, 58(1), pp.85-87.
Takubo, K., Honma, N., Sawabe, M., Arai, T., Izumiyama-Shimomura, N., Kammori, M., Sasajima, K. and Esaki, Y., 2002.

Clinical Case Summary

Introduction: Myeloid sarcoma (MS) is a rare neoplasm composed of immature myeloid cells, which can occur de novo or in association with hematologic malignancies such as acute myeloid leukemia (AML). Gastric involvement is rare.
Case Report: A 56-year-old woman with a medical history of acute myeloid leukemia (AML) with inv(16). Following two unsuccessful induction therapy cycles, she underwent two unrelated allogeneic hematopoietic stem cell transplantations (HSCT). During the second post-HSCT period, she developed grade I gastrointestinal graft-versus-host disease (GI GVHD), confirmed by biopsy and managed with budesonide.
Five months post-HSCT, the patient was admitted due to upper gastrointestinal bleeding (melena) and worsening anemia (Hb: 5,6 g/dL). Gastroscopy revealed multiple hemorrhagic suffusions, petechial areas, nodular formations with erythematous borders, and eroded centers that bled upon contact and were not amenable to endoscopic treatment (Figure 1). Biopsies were performed to exclude GI GVHD and viral superinfection. Histological examination revealed acute myeloid leukemia (myeloid sarcoma) infiltration in the gastric mucosa (Figure 2). Six months post-HSCT, the patient succumbed to AML progression.
Discussion:
- Myeloid Sarcoma (MS) typically affects the skin, lymph nodes, and brain, making its occurrence in the gastrointestinal tract uncommon.
- Endoscopic imaging may mimic other conditions therefore biopsies are required to confirm the diagnosis.
- In hematologic patients post-HSCT, endoscopic evaluations are essential for diagnosing gastrointestinal complications such as opportunistic infections, GI graft-versus-host disease (GI GVHD), and progression of their underlying disease. Our case highlights the rarity of gastric MS.

References

Figure 1: Gastroscopic images (A and B) depicting multiple hemorrhagic suffusions, petechial areas, nodular formations with erythematous borders, and eroded centers.

Figure 2: Histological examination of gastric and oxyntic mucosa biopsies revealing lamina propria occupation by small to medium immature blast cells, consistent with acute myeloid leukemia infiltration of the gastric mucosa (previously identified).

Clinical Case Summary

Introduction: Nonvariceal upper gastrointestinal bleeding is mostly due to peptic ulcer disease [1]. Occasionally, gastric malignancy may be implicated in these situations [2]. Here, we report a case of nonvariceal upper gastrointestinal bleeding as the only manifestation of gastric bladder carcinoma metastasis.
Discussion: A 81 years old caucasian man performed a bladder endoscopic resection for a non metastatic bladder carcinoma in January 2022 with a negative follow up since October 2023 when the patient was hospitalized for a melena episode.
During the hospitalization, an esophagogastroduodenoscopy (EGD) was performed and showed a large gastric fundic lesion covered with flat pigmented clots, that was sampled: at the histological evaluation a gastric metastasis of bladder carcinoma was found. The patient, then, performed a thorax and abdomen computed tomography (CT) scan that didn’t show bladder neoplastic recurrence or other metastasis sites. The patient, so, performed a wedge gastric resection and then started chemotherapy that is now ongoing with good response.
Conclusion: We describe, as we know, the first case of a nonvariceal upper gastrointestinal bleeding as the only manifestation of bladder cancer recurrence. Indeed, in our clinical practice, neoplastic lesions aren’t routinely taken into account, in the differential diagnosis of nonvariceal upper gastrointestinal bleeding.

References

1. Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021 Mar;53(3):300-332. doi: 10.1055/a-1369-5274. Epub 2021 Feb 10. PMID: 33567467.

2. Kate V, Sureshkumar S, Gurushankari B, Kalayarasan R. Acute Upper Non-variceal and Lower Gastrointestinal Bleeding. J Gastrointest Surg. 2022 Apr;26(4):932-949. doi: 10.1007/s11605-022-05258-4. Epub 2022 Jan 26. PMID: 35083723.

Introduction

Gastric squamous cell carcinoma (GSCC) is an aggressive rare histological subtype accounting for 0.04-0.5% only of all gastric tumors. Due to its scarcity, there are very few case reports in the literature and data are limited to institutional case series with significant variations. Thus, no recommendations for GSCC were published by the European Society of Medical Oncology or the National Comprehensive Cancer Network societies.

Aims & Methods

The aim of this study is to provide the literature with an updated evidence about this rare type for better understanding for its nature and establish a proper management strategy. Data were extracted from the Surveillance, Epidemiology and End Results (SEER) database for 784 patients diagnosed with primary GSCC with sequence 0 or 1 from 2000 to 2020. Patients were selected based on microscopic confirmation for the diagnosis . We used a rate session to calculate the age-adjusted trends as Percent Chance (PC) and Annual Percent Change (APC). We subdivided the patients according to the treatment modality into medical therapy, partial gastrectomy and total gastrectomy group, then followed by smaller subgroups (primary therapy and surgery with systemic therapy) . We used a survival session to calculate the relative survival. SPSS version 23 was used for data analysis, Kaplan-Meier and Log-Rank test for survival analysis. The results were considered significant when P <0.05.

Results

GSCC had 2000-2020 PC of -13.3 [APC= -0.5, 95% CI (-1.6: 0.6), P>0.05]. African-Americans had increased rate compared to Caucasians (RR=2.32, 95%CI: 1.96-2.73, P<0.0001). The overall 3-year and 5-year relative survival of GSCC were 21.7% and 17.4%. Out of 502 patients, 341(68.1%) received medical treatment only, 43(8.6%) had partial gastrectomy and 117(23.3%) had total gastrectomy with 5-year relative survival of 10.4%, 38.1% and 44.6% respectively; P<0.0001. Adjuvant chemoradiotherapy had similar 5-year survival compared to surgery with no systemic therapy while both had improved survival compared to surgical management with systemic chemotherapy only (43.4%, 51.5% and 22.9% respectively; P=0.07). Among the group who received systemic therapy only, primary chemoradiotherapy had improved 5-year relative survival compared to primary chemotherapy and primary radiotherapy (16.3%, 8.1% and 0.0%; P<0.0001).

Conclusion

GSCC is an aggressive malignancy with poor survival outcome. GSCC rates have decreased over the past 20 years. However, the rate in African-Americans is two folds greater to develop GSCC compared to Caucasians. Total gastrectomy had significant improved survival compared to partial gastrectomy and the medical treatment. These results highlights total gastrectomy as the modality of choice for primary GSCC. As adjuvant chemoradiotherapy had no significant benefit over surgery with no systemic therapy, we discourage the use of systemic therapy to avoid serious systemic side effects related to the systemic treatment for better quality of life after the surgical management.

References

1. de Lange G, Bouroumeau A, Coron E, Koessler T. Gastric squamous cell carcinoma: A rare malignancy, literature review and management recommendations (Review). Mol Clin Oncol. 2023;19(4):2–7.
2. Dong C, Jiang M, Tan Y, Kong Y, Yang Z, Zhong C, et al. The clinicopathological features and prognostic factors of gastric squamous cell carcinoma. Med (United States). 2016;95(34):1–7.
3. Akce M, Jiang R, Alese OB, Shaib WL, Wu C, Behera M, et al. Gastric squamous cell carcinoma and gastric adenosquamous carcinoma, clinical features and outcomes of rare clinical entities: A National Cancer Database (NCDB) analysis. J Gastrointest Oncol. 2019;10(1):85–94.

Introduction

Systemic anticoagulants are often prescribed to prevent and treat thromboembolism among other indications, yet presentations with Acute Upper Gastrointestinal Bleeds (AUGIB) in this cohort are common. Medical care bundles have been shown to improve both standards of care and patient outcomes. As a result, the British Society for Gastroenterology (BSG) created an AUGIB care bundle in 2019, and guidelines for endoscopy in patients on antiplatelets and anticoagulants in 2021. However, the former lacks definitive statements regarding resumption of antiplatelet/anticoagulant therapy, while the latter is not routinely referred to by non-Gastrointestinal specialists. It is recognised however, that resumption of antiplatelets and anticoagulants is associated with improved survival and reduced incidence of thrombotic complications. Thus, all patients should have a clear plan.

Aims & Methods

Admissions with AUGIB proceeding to endoscopy over a 6 month period were analysed. Of the 319 patients, 72 (22.5%) were taking either an antiplatelet, warfarin or a Direct Oral Anticoagulant (DOAC). Medical records were reviewed in relation to pre-procedure management of these medications, advice from the endoscopist regarding resumption (or not) of antithrombotic therapy and whether these medicines were managed appropriately thereafter.
Several interventions were then made; a change to the reporting software led to a prompt relating to antiplatelet/anticoagulant medications (though the template remains non-specific), an education campaign for post graduate doctors in training and medication guidance summaries visible in the endoscopy department.
A second 6-month review was then undertaken to evaluate if there had been any improvement in outcomes. In this time frame, 283 patients underwent endoscopic evaluation for suspected AUGIB of whom 83 (29.3%) were taking antithrombotic therapy.

Results

Results can be found in Table 1:

	Pre-Intervention	Post Intervention
Pre-procedure appropriate management	76%	81%
Documented advice on endoscopy report	35%	65%
Post procedure appropriate prescribing	68%	75%

A recurring theme was the discontinuation of aspirin in low-risk bleeds, and low quality medication advice given at the time of endoscopy with almost 4 in 10 reports simply stating ‘continue medication’. Those without documentation resulted in further advice being sought (12.9% of cases)
Further subanalysis of the data revealed that advice was almost always documented in those presenting with major upper gastrointestinal bleeds (defined as patients presenting with haemodynamic instability). In this cohort 87.5% of patients had clearly documented advice regarding their anticoagulation or antiplatelet medication.

Conclusion

Further education to junior staff around utility of the BSG AUGIB bundle, as well as the anticoagulation guidelines is needed to improve pre and post procedure care. Further upgrades to the templates on the reporting software will also serve as prompts to the endoscopist to provide more specific advice. Human factors also need to be considered; limited advice is likely related to the high endoscopy workload pressures. Sub-analysis of the data suggests that we are better at providing more specific advice in high-risk bleeds/where endotherapy is required, reflecting that antithrombotic therapy decisions are considered by the endoscopist. Improved documentation at procedure, should translate into improved post procedure management and reduce further demands on the service.

References

BSG AUGIB bundle : Siau K, Hearnshaw S, Stanley AJ, et al. Frontline Gastroenterology 27/03/2020. doi:10.1136/ f lgastro-2019-101395
Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline updateVeitch AM, Radaelli F, Alikhan R, et al. Gut 2021;70:1611–1628

Introduction

Prophylactic total gastrectomy (PTG) is the definitive treatment for hereditary diffuse gastric cancer syndrome (HDGC). Endoscopic surveillance informs the requirement and optimal timing to surgery. However, endoscopic recognition of early signet ring cell carcinoma (SRCC) remains challenging. In this study, we aimed to develop and prospectively validate a user-friendly diagnostic framework with machine-learning to support endoscopists in accurate identification of early SRCC during surveillance in HDGC individuals.

Aims & Methods

We retrospectively analysed 147 HDGC individuals undergoing endoscopic surveillance to evaluate the diagnostic accuracy of endoscopic criteria (Cambridge criteria), develop a clinical decision tree (cDT) to better apply the criteria based on machine leaning, and investigate its clinical significance. We then prospectively validated cDT in 66 CDH1 pathogenic-variant carriers. The inter-observer agreement and diagnostic accuracy of Cambridge criteria and cDT were assessed through multi-reader multi-case study.

Results

Retrospective analysis of 537 endoscopies showed Cambridge criteria achieved 82.8% (48/58) sensitivity and 78.2% (140/179) specificity for SRCC diagnosis. The presence and number of neoplastic pale areas are independent predictors of higher cancer burden in HDGC individuals. In prospective study, cDT had 77.8% (21/27) sensitivity and 90.7% (49/54) specificity. The cDT significantly improved average sensitivity among non-experts from 66.7% to 72.5% and 87.5%, and among experts from 74.1% to 80.0% and 91.7% (P = 0.03).

Conclusion

We developed and validated a practical endoscopic framework to enhance SRCC assessment during HDGC endoscopic surveillance.

Introduction

Massive gastrointestinal bleeding (MGB) is a life-threatening condition that requires prompt recognition and resuscitation to increase the chance of good outcomes (1).

Aims & Methods

Aims: Analyze risk factors, comorbidities and outcomes of MGB.
Methods: Retrospective analysis of a prospective registry of upper gastrointestinal bleed (UGIB) patients admitted to ‘Virgen de las Nieves University Hospital’ between 2013-2020.
MGB was defined as UGIB with transfusion of >2 pRBCs in the emergency room or during the first 24h of hospital stay and signs of shock (2). Main outcomes were 30-day mortality, rebleeding, bleeding persistence or severe complication throughout admission and complications within the first 6 months after discharge (including cardiovascular, hemorrhagic or deaths).
Statistical analysis was performed by SPSS.

Results

We included 1213 UGIB patients, 171 with MGB.
Multivariate logistic regression analysis showed that, being admitted for another condition (HR 1.72,95%CI 1.04-2.58,p=0.035), having a systemic disease (HR 2.30,95%CI 1.22-5.32,p=0.045), a disseminated malignancy (HR 2.07,95%CI 1.02-4.21,p=0.045) or suffering a severe comorbidity (HR 2.21,95%CI 1.25-3.91,p=0.009) were independent risk factor for MGB.
Among 171 MGB patients, 21% died, with 10 deaths directly from hypovolemic shock secondary to UGIB, and 11% due to complications.
Table shows significance differences between deaths and survivors.

Relevant Comorbidities ASA 3-4 (%)	Deaths 96.7%	Survivors 78.5%	p 0.0018
Active bleeding (%)	76.3	43.3	0.007
Interventional radiology (%)	13.3	3.7	0.034
SBP (mean±SD mmHg)	79±8	84±9	0.025
Albumin (mean±SD mg/dl)	2.4±0.5	2.8±0.6	0.011
Calcium (mean±SD mg/dl)	7.7±0.6	8.2±0.8	0.032
Platelets (mean±SD /mm3)	158*103±101*103	206*103±106*103	0.027
Severe complications during hospitalization	76.7	22.1	<0.0001
Bleeding persistence (%)	63.3	17.6	<0.0001
Rebleeding (%)	40	17	0.005

Multivariate analysis showed that active bleeding in endoscopy (HR 4.80,95%CI 1.06-21.62,p=0.041) and severe complications (HR 14.03,95%CI 3.30-59.60,p<0.0001) were independent predictors for mortality, being calcium levels a protective factor (HR 0.41,95%CI 0.16-0.94,p=0.045).
Among the survivors after the index episode,14% died after 6 months, being main causes of death recurrent bleeding(5.2%), neoplasms(4.4%), cirrhosis complications(2%), cardiovascular disease(1.5%) and sepsis(1.5%).
Delayed bleeding was caused by recurrent UGIB in 86.6%, lower GIB in 10% and from a non-GI origin in 3.4%. Delayed cardiovascular events were heart failure in 46%, thromboembolic events in 23%, myocardial ischemia in 15.4% and atrial fibrillation in 15.6%.

Conclusion

Our study is a prospectively collected single center registry of patients with massive UGIB, in which we observed that being an inpatient and harboring severe comorbidities, particularly systemic diseases and malignancies, were risk factors for this condition. Mortality among those patients was related to CKD, cirrhosis, severe comorbidities and excessive alcohol consumption. We also found an increased delayed mortality, probably related to a worsening health condition in which GI bleeding heralded poor outcomes, some of them potentially preventable with close follow-up.

References

1. Nagata N, Sakurai T, Shimbo T, et al. Acute Severe Gastrointestinal Tract Bleeding Is Associated With an Increased Risk of Thromboembolism and Death. Clin Gastroenterol Hepatol. 2017;15:1882-1889 e1881.
2. D'Amore K, Swaminathan A. Massive Gastrointestinal Hemorrhage. Emerg Med Clin North Am. 2020;38:871-889.