Endoscopic signs of benign gastric tumors

A polyp is a benign tumor of epithelial tissue growing into the lumen of an organ. The term "polyp" originated to define formations on the mucous membrane of the nasal passages. The first description of the macroscopic state of a gastric polyp was made by Omatus Lusinatus in 1557. Based on a clinical examination, the diagnosis of a gastric polyp was first made by Obraztsov - during a study of gastric lavage waters. In 1912, Khosref, operating on this patient, found a polyp in her. Schindler was the first to discover a polyp during gastroscopy in 1923. Currently, gastric polyps include regenerative, inflammatory and tumor changes in the mucous membrane.

Frequency of the disease. Gastric polyps are diagnosed:

• 0.5% of all sections,
• 0.6% of patients with gastric X-ray,
• 2.0-2.2% of patients referred for gastroscopy.

Localization. Antral section - 58.5% of all gastric polyps, body of the stomach - 23.2%, cardia - 2.5%. At the level of the esophagus and duodenum from 0.01 to 0.18% of cases.

Polyps can be single or multiple. If several polyps are formed within one segment of the organ - multiple polyps, if in two or more segments of the organ - polyposis. About 50% of gastric polyps are asymptomatic.

Causes of polyp formation.

1. Inflammatory theory (Slavyansky and his students). A polyp is the result of ongoing inflammation of the gastrointestinal tract. During inflammation, exudation and proliferation develop. When the proliferation of glandular epithelium prevails over the integumentary epithelium, a polyp occurs. The next stage of polyp development is cancer (there is currently no data for this).
2. Theory of embryonic ectopia (Davydovsky, 1934). Formation of a polyp is the result of embryonic ectopia. As an example - polyps in children and embryos.
3. Dysregenerative theory (Lozovsky, 1947). Inflammation plays a role in the formation of polyps, but in itself it does not determine the necessity of polyp formation. The mucous membrane of the gastrointestinal tract has a very high growth potential, which compensates for tissue damage during inflammation, but if trauma occurs frequently, regeneration (coordination between the proliferation process and the stabilization process) is disrupted and a polyp is formed.

Classification of polyps

Anatomical classification of polyps.

• By leg shape:
  • pedunculated polyps - have a clearly defined stalk and head, and are characterized by a main type of blood supply;
  • polyps on a broad base - do not have a stalk, their base is clearly delimited, unlike submucous and polypoid tumors. Scattered type of blood supply is characteristic.
• By polyp shape:
  • spherical,
  • cylindrical,
  • mushroom-shaped,
  • conical,
  • flat.
• Conical and flat polyps usually do not have a stalk and have a scattered blood supply.

Morphological classification of polyps (WHO).

• Adenomas.
  • papillary;
  • tubular.
• Inflammatory polyps (eosinophilic granulomas).
• Peutz-Jeghers polyps.

Adenomas. They are growths of glandular epithelium and stroma. In papillary adenomas, the glandular epithelium is in the form of separate strands, in tubular adenomas - in the form of branching structures penetrating the entire polyp. They usually have a smooth surface, soft consistency, the color depends on changes in the mucous membrane covering the polyp (usually inflammatory): it can be reddish, bright red, spotted - erosions with fibrin plaque.

When captured, polyps are displaced together with the mucous membrane from which they originate, forming a fold in the form of a pseudopod. When the polyp is pulled and displaced, it does not change its shape. Bleeding during biopsy is inactive. Adenomas can be hyperplastic when there is atypia (for example, intestinal epithelium). Adenomatous polyps are classified as precancerous diseases.

Inflammatory (hyperplastic) polyps. They account for 70-90% of all gastric polyps. They develop as a result of hyperplasia of fibrous and lymphoid structures from the submucosal layer or from the proper plate of the mucous membrane. Lymphoid, histiocytic and plasmacytic infiltration with an admixture of eosinophils is determined. They are most often located on the mucous membrane of the antrum or the lower third of the body of the stomach. They often accompany a duodenal ulcer (bulb), in which the function of the pylorus is impaired, which leads to bile reflux, and bile causes inflammatory changes in the gastric mucosa and the formation of erosions. They look like rounded-cylindrical elevations on the mucous membrane on a wide base with a flattened apex, in the area of flattening or erosion, or whitish-gray scar tissue. The consistency is dense.

Peutz-Jeghers polyps. Multiple polyps, externally not much different from adenomas, but have a dense consistency. They have a richly branched smooth muscle stroma that penetrates the entire polyp. The mucous polyp has a normal glandular structure. They are most often located on the border of the antral section with the body of the stomach.

Submucosal (non-epithelial) tumors of the stomach

Some tumor-like formations may not be polyps, but submucous tumors and other formations. They grow from non-epithelial (nervous, muscular, adipose, connective) tissue, are often mixed and can be benign and malignant. Macroscopic diagnostics of submucous tumors is difficult due to the identity of endoscopic signs of epithelial, non-epithelial and inflammatory neoplasms. The frequency of establishing the correct diagnosis based on visual data is 48-55%.

The endoscopic picture of submucous tumors is determined by the nature of their growth, location in the organ wall, size, presence of complications, endoscopic examination technique, amount of air injected and degree of stretching of the stomach walls: the more air is injected and the more the walls are stretched, the more prominent and distinct the tumor. Tumor growth can be exo-, endophytic and intramural.

In typical cases, submucous tumors are round-shaped neoplasms (from flattened to hemispherical depending on the depth of location) with defined borders. They can be of different sizes - from small (1-2 cm) to significant (10-20 cm). The latter occupy a larger part of the organ, and their thorough revision is impossible.

The surface of submucous tumors depends on the nature of the mucous membrane covering it. It can be smooth or folded. During instrumental "palpation", the mucous membrane over large tumors is usually mobile, and in the presence of inflammatory changes, it is fused with the tumor tissue and immobile. The mucous membrane of small submucous tumors is slightly mobile.

The mucous membrane above the tumors is usually unchanged, but inflammatory (edema, hyperemia) and destructive (hemorrhages, erosions, ulcerations) changes may be observed. Often, mucous membrane retractions are detected due to its adhesion to the tumor tissue. The base of submucous tumors is poorly differentiated due to the presence of folds in the mucous membrane. When air is pumped in, the folds straighten out and the base of the tumor is better contoured. With instrumental "palpation", the consistency and mobility of the tumor can be determined.

It is very difficult to determine the morphological structure (lipoma, myoma) and benignity of the tumor based on visual data. Macroscopically benign tumors (with an unchanged mucous membrane, a pronounced base) may turn out to be malignant and, conversely, malignant tumors - benign. However, there are signs due to which, during an endoscopic examination, it is possible to state with a certain degree of probability that the tumor is benign:

1. Tent sign: the mucosa over the tumor can be raised with biopsy forceps like a tent.
2. Schindler's sign: convergence of mucosal folds to the tumor in the form of tracks.
3. Pillow sign: the surface of the tumor may be depressed when pressing on it with biopsy forceps (for example, with a lipoma).

Fibroma. Originates from the submucosal layer of the stomach. Very dense consistency. When palpated, it slips out from under the palpator (no fusion with the mucosa). Positive tent symptom. Biopsy does not provide an idea of the nature of the submucosal tumor.

Lipoma. Originates from the submucous or subserous layers. Difficulties in differential diagnostics arise mainly with lipomas located in the submucous layer. Soft on palpation, does not slip when in contact with an instrument. If the tumor is pressed by a palpator, an indentation is formed in it. Biopsy shows unchanged mucosa.

Leiomyoma. Most often conical in shape. The mucous membrane above it is often intensely red (the tumor shows through). The consistency is soft. On its surface, it is sometimes possible to trace radial striations in the form of narrow reddish stripes - vessels (the tumor is well supplied with blood). Often, the tumor grows into the mucous membrane - then, during a biopsy, it is possible to establish its morphological structure. Bleeding during a biopsy is active.

Xanthoma. The tumor consists of lipophages. The tumor is yellowish in color. The shape varies, most often irregularly round or oval. It protrudes slightly above the surface of the mucous membrane. The size ranges from pinpoint to 0.6-1.0 cm. It actively bleeds during biopsy.

A biopsy always confirms the morphological structure. Xanthomas on the duodenal mucosa require special attention, as they can be confused with carcinoid, which becomes malignant much more often.

Ectopic pancreas. Always located in the antral section on the posterior wall or greater curvature, closer to the pylorus. In appearance, it resembles an inflammatory polyp, in contrast to which there are no erosions or fibrously altered tissues in the area of the flattened apex. A distinctive feature is an opening in the center of the apex, corresponding to a rudimentary duct. When the apex of the tumor is captured with biopsy forceps, it moves freely in the form of a proboscis; when released, it is again drawn into the apex of the tumor, without preserving the shape of the proboscis.

Carcinoid. This is a tumor that occupies an intermediate position between benign and malignant tumors. It originates from the tissue of the basement membrane of the mucous membrane. It is stained with silver - an argentophilic tumor of the gastrointestinal tract. It has a round or conical shape, a wide base, delimited from the surrounding tissues. The color is usually spotty due to the alternation of whitish-reddish tones. It has a tendency to early erosion and metastasis. The true nature is accurately established based on a biopsy.

Lymphofollicular hyperplasia. Hyperplasia in the lymphoid apparatus of the mucous membrane or submucous layer. Rounded formations on a wide base. Sizes can be from point to 0.3-0.4 cm. Dense consistency. The mucosa within the granulomas is infiltrated. Biopsy reveals lymphoid and histiocytic infiltration with an admixture of intestinal-type glands. The color is grayish-whitish or grayish-yellowish.

Melanoma metastases to the gastric mucosa. They have a round-cylindrical shape, resemble an inflammatory polyp, in contrast to which, in the area of the flattened apex, the mucosa is bluish-smoky or brown. During biopsy, bleeding is normal or reduced. Fragmentation is noted. The consistency is dense. The true nature is established on the basis of a biopsy.

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