Endosonographic Evaluation of Hypertrophied Gastric Folds with Curved Array Transducer

By Dr.Rayadh, A.Zaydan CABM FICM.GE+H

Gastroenterology and hepatology teaching hospital Baghdad

Back ground and study aims: Hypertrophied gastric folds are frequent findings on the radiologic and endoscopic examination. Endoscopic ultrasonography (EUS) was performed for those patients to determine the diagnostic usefulness of EUS in the evaluation of hypertrophied gastric folds. Patients and Methods: Participants were 42 patients with hypertrophied gastric folds visualized by endoscopic examination .EUS was carried out by single endosonographer using curved array transducer with frequency 7.5 MHz . Results : EUS examination revealed normal gastric wall thickness with intact wall layers in 20/42 patients and hypoechoic thickening of gastric wall with or without loss of echo layers in the 22/42 (16 had adnocarcinoma, 3 had lymphoma, 2 had maltoma and 1 had eosinophilic gastroenteritis ). Conclusion : EUS is very usefull in the evaluation of hypertrophied gastric folds because it has excellent accuracy in the detection of abnormally thickened gastric wall , but it has limited capability in differentiation between benign and malignant condition responsible for gastric wall thickness . Introduction : Abnormalities suggesting hypertrophied gastric folds are found frequently in patients undergoing routine upper gastrointestinal endoscopy (1). Endoscopic ultrasonography (EUS) has an excellent accuracy in determining gastric wall thickness (normal 3-6 mm) and good capability in the visualizing wall layers with high resolution .Scanning of gastric wall by EUS results in echo layers which loosely correspond to the histological layers (2). The number of these echo layers are increase or decrease according to the frequency of transducer used for scanning .So scanning of gastric wall with trasducer frequency of 7.5-

12 MHZ results in 5 echo layers which has been histologically confirmed that the first and second echo layer correspond to the mucosa, the third hyperechoic layer correspond to the submucosa ,the fourth hypoechoic layer correspond to the muscularis propria and fifth hyperechoic layer to serosa .Using high frequency (2030MHz) transducer results in 9 layers structure: in addition to the five layer, there is border echo of the muscularis mucosa and hyperechoic septation between the inner and outer muscular layer (3,4) .So the higher the frequency of the transducer used in the evaluation of stomach the higher the capability in assessing the gastric wall (5). Because of this capability of EUS in the assessment of gastric wall, it is use now in the evaluation of hypertrophied gastric folds for : - Determination the thickness of gastric wall . - Detection of any disturbance in the normal echo-pattern of wall layers (6,7,8,9) Patients and methods : This study included 42 patients had prominent gastric folds with or without mucosal congestion and /or ulceration visualized by upper endoscopic examination, and initial histological study of endoscopy biopsies were either normal or gastritis . Both male (26)and female (16) were included in this study with a median age of 50 years (range 20-75 years) .All these patients were assessed clinically by thorough history and physical examination and were evaluated by abdominal ultrasonography and/or abdominal computed tomography scanning before endoscopic examination . Upper endoscopic examination with conventional forceps biopsies were carried out before EUS study .

EUS examination were performed by pentax FG34UX with curved array trarsducer using frequency of 7.5 MHz, under diazepam or pethidin. Scanning of gastric wall by transducer was done by using balloon method or using a conventional water filling technique . Follow up of these patients histopathologically was done by conventional forceps biopsy and/or by laparoscopic biopsy .

Results: The initial histopathological results of forceps biopsies of these patients with hypertrophied gastric folds were either normal or gastritis. Scanning of these hypertrophied gastric folds by EUS demonstrated normal gastric wall thickness (3-5 mm) with preservation of normal echo pattern of

gastric wall layers in 20/42 patients. Other 20/42 patients were fond to have by EUS study a hypoechoic transmural thickening of the gastric wall (8-15mm) with loss of normal echo pattern of gastric wall layers . Histopathological study of repeated endoscopic biopsies after EUS examination of these 20 patients with thickened gastric folds verified malignancy in 19 patients (16 had adenocarcinoma and 3 had lymphoma) Eosinophilic gastroenteritis was confirmed by laparoscopic biopsy in 1/20 patient with thickened gastric wall . Hypoechoic thickening of second layers (muscularis mucosa ) of gastric wall (4 mm) with preservation of outer layers were demonstrated by EUS examination in 2/42 patients .Histopathological study of repeated endoscopic biopsies confirmed maltoma in these 2 patients .

Table (1) EUS findings and histopathologicical resultes of 42 patients with hypertrophied gastric folds. No 20 16 3 1 2 EUS findings Normal gastric wall Hypoechoic transmural thickening of the wall Hypoechoic transmural thickening of the wall Hypoechoic transmural thickening of the wall Histopathologicical Results Normal or gastritis Adenocaricinoma Lymphoma Eosinophilic gastritis

Hypoechoic thickening of second wall layer Maltoma (muscularis mucosa )

Discussion: Hypertrophied gastric folds with normal or non- conclusive conventional endoscopic biopsies results still problematic condition that facing the gastroenterologist until using EUS in the evaluation of giant gastric folds. One of great strength of EUS is the ability to image gastric wall layers. In this study 42 patients with hypertrophied gastric folds were evaluated by EUS which has an excellent capability in the detection of abnormally thickened gastric wall. Songur y.et al (10) reported that EUS is an excellent method for detection of infiltrative abnormalities below the mucosa . In the present study normal gastric wall layers detected by EUS definitely exclude infiltrative process. But diffuse transmural lesions involving all gastric wall layers would be evident at EUS, and strongly suggest the possibility of infiltrating neoplasm, although a benign process (e.g..eosinophilic gastritis) is also possible. In such cases deeper endoscopic or laparoscopic biopsy might be needed to obtain pathological diagnosis . In a study done by Petrer Vilmann et al (2) in Copenhagen which included 55 patients with hypertrophied gastric folds were evaluated by curved array transducer ,EUS was able to excluded gastric cancer in the great majority of those patients .Misdiagnosis by EUS examination was occurred in 3 patents with thicken gastric wall. Vilmann explained the cause of this misdiagnosis was due to difficulty in differentiation between inflammation and cancer in 2 patients and to the inexperience since EUS misjudged the antrum near the pyloric area with physiological thickened fourth layers (muscularis

propria) as linitis plastica wall. In our study misdiagnosis was occurred in 1 patients with thickened gastric wall which considered by EUS as infiltrative process but final diagnosis was confirmed histopathologically as eosinophilic gastritis. This misdiagnosis also due to inability to differentiate between benign and malignant conditions that responsible for gastric wall thickening . In conclusion, EUS is very useful in the evaluation of hypertrophied gastric folds since it has excellent capability in the determination of pathologically thickened gastric wall . Although normal gastric wall thickness and normal wall layers as demonstrated by EUS examination exclude neoplastic process, but it is difficult to differentiate between a benign and malignant conditions that responsible for gastric wall thickening .So Histopathological study of biopsies (endoscopic, laparoscopic or surgical )still valuable in the determination of different causes of gastric wall thickening .

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10.Songus

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