Endoscopic signs of benign gastric tumors

Polyp is a benign tumor of epithelial tissue that grows in the lumen of the organ. The term "polyp" arose for the definition of formations on the nasal mucosa. The first description of the macroscopic state of the polyp of the stomach was made by Omatus Lusinatus in 1557. On the basis of the clinical examination, the diagnosis of the polyp of the stomach was first put by Obraztsov - in the study of gastric washings. In 1912, Khosref, using this patient, found a polyp in her. For the first time in a gastroscopy polyp found Schindler in 1923. At present, the gastric polyps include regenerative, inflammatory and tumor changes in the mucosa.

Frequency of disease. Polyps of the stomach are diagnosed:

• 0.5% of all sections,
• 0,6% of patients with fluoroscopy of the stomach,
• 2,0-2,2% of patients aimed at gastroscopy.

Localization. Antral department - 58.5% of all stomach 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 and 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 the stomach polyps are asymptomatic.

The reasons for the formation of polyps.

1. Inflammatory theory (Slavyansky and his students). Polyp is the result of continuing inflammation of the gastrointestinal tract. With inflammation develops exudation and proliferation. When the proliferation of glandular epithelium predominates over the integumentary epithelium, a polyp arises. The next stage of development is polypacar (at present there is no data for this).
2. The theory of embryonic ectopy (Davydovsky, 1934). The formation of a polyp is the result of embryonic ectopy. As an example - polyps in children and embryos.
3. Disregerator theory (Lozovsky, 1947). Inflammation plays a role in the formation of polyps, but in itself it does not determine the need for polyps. The mucous membrane of the gastrointestinal tract has a very high potential for growth, which compensates for tissue damage in inflammation, but if the 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.

• According to the shape of the foot:
  • polyps on the leg - have a clearly expressed leg and head, they are characterized by a main type of blood supply;
  • polyps on a wide base - do not have a pedicle, their base is clearly delineated, in contrast to submucosal and polypoid tumors. A loose type of blood supply is characteristic.
• According to the shape of the polyp:
  • globular,
  • cylindrical,
  • mushroom,
  • conical,
  • flat.
• Conical and flat polyps usually do not have a leg, blood supply in a loose type.

Morphological classification of polyps (WHO).

• Adenomas.
  • papillary;
  • tubular.
• Inflammatory polyps (eosinophilic granulomas).
• Polyps of Peitz-Jagers.

Adenomas. They represent proliferation of glandular epithelium and stroma. In papillary adenomas glandular epithelium in the form of separate strands, in tubular adenomas - in the form of branching structures that permeate the entire polyp. Usually they have an even surface, soft consistency, color depends on the changes in the mucous membrane covering the polyp (more often of an inflammatory nature): it can be reddish, bright red, spotted - erosion with a fibrin plaque.

When the polyps are captured, they are displaced along with the mucosa from which they emerge, thus forming a fold in the form of a pseudopod. When pulling and shifting the polyp, it does not change its shape. Bleeding during biopsy is inactive. Adenomas can be hyperplastic when there is atypia (eg, intestinal epithelium). Adenomatous polyps are classified as precancerous diseases.

Inflammatory (hyperplastic) polyps. They constitute 70-90% of all stomach polyps. Developed as a result of hyperplasia of fibrotic and lymphoid structures from the submucosa or from a propria of the mucous membrane. Lymphoid, histiocytic and plasmocyte infiltration with an admixture of eosinophils is determined. Most often located on the mucosa of the antrum or the lower third of the body of the stomach. Often accompanied by an ulcer of the duodenum (bulb), in which the function of the gatekeeper is disrupted, which leads to reflux of bile, and bile causes inflammatory changes in the gastric mucosa and the formation of erosion. They look like rounded-cylindrical elevations on the mucosa on a broad base with a flattened apex, in flattening or erosion, or a whitish-gray scar tissue. Consistency is dense.

Polyps of Peitz-Jagers. Multiple polyps, apparently not much different from adenomas, but have a dense consistency. They have a richly ramified smooth muscle stroma that permeates the entire polyp. Mucous polyp has a common glandular structure. Are located more often on the border of the antrum with the body of the stomach.

Submucosal (non-epithelial) tumors of the stomach

Some tumoral formations may not be polyps, but submucosal tumors and other formations. They grow from non-epithelial (nervous, muscular, fatty, connective) tissues, often are mixed and can be benign and malignant. Macroscopic diagnosis of submucosal tumors is difficult due to the identity of endoscopic features of epithelial, non-epithelial and inflammatory neoplasms. The frequency of establishing the correct diagnosis on the basis of visual data is 48-55%.

The endoscopic picture of submucosal tumors is determined by the nature of their growth, the location in the organ wall, the size, the presence of complications, the technique of endoscopic examination, the amount of air introduced and the extent of stretching of the stomach walls: the more air is pumped and the walls are stretched more sharply, the more sharply and sharply the tumor. The growth of tumors can be exo-, endophytic and intramural.

In typical cases submucosal tumors are tumors of rounded shape (from flattened to hemispherical depending on depth of location) with outlined boundaries. Can be of different sizes - from small (1-2 cm) to significant (10-20 cm). The latter occupy most of the body, and careful revision of them is impossible.

The surface of submucosal tumors depends on the nature of the mucous membrane covering it. It can be flat and folded. With instrumental "palpation", the mucosa over large tumors is usually mobile, and in the presence of inflammatory changes it is soldered to the tumor tissue and immobile. Mucous small submucosal tumors are inactive.

The mucous membrane over the tumors is usually not changed, but inflammatory (edema, hyperemia) and destructive (hemorrhage, erosion, ulceration) can be noted. Often there are mucosal entrainments caused by its adhesion to the tumor tissue. The base of submucosal tumors is poorly differentiated due to the presence of folds of the mucous membrane. When the air is forced, the folds straightens and the base of the tumor is contoured better. With instrumental "palpation" you can determine the consistency and mobility of the tumor.

Based on visual data, it is very difficult to determine the morphological structure (lipoma, myoma) and the goodness of the tumor. Macroscopically benign tumors (with unchanged mucous membrane, pronounced basement) may turn out to be malignant and, conversely, malignant by type of tumor - benign. There are, however, signs that, with endoscopic examination, it is possible to affirm with a certain degree of probability that the tumor is of good quality:

1. Symptom of the tent: the mucous membrane above the tumor can be raised using biopsy forceps as a tent.
2. Schindler's symptom: the convergence of the folds of the mucosa to a tumor in the form of tracks.
3. Symptom of the pillow: the surface of the tumor can be pressed down by pressing it with biopsy forceps (for example, with lipoma).

Fibroma. It comes from the submucosal layer of the stomach. Very dense consistency. When palpation slips out from under the palpator (there is no fusion with the mucosa). A positive symptom of the tent. A biopsy does not give an idea of the nature of the submucosal tumor.

Lipoma. It comes from the submucosal or subscerous layer. Difficulties in differential diagnosis occur mainly with lipomas located in the submucosa. At palpation soft, at contact to the tool does not slip. If the tumor is squashed by the palpator, an impression is formed in it. When biopsy - unchanged mucous.

Leiomyoma. More often conical shape. The color of the mucosa over it is often intensely red (the tumor shows through). Consistency is soft. On its surface it is sometimes possible to trace the radial striation in the form of narrow bands of reddish color - the vessels (the tumor is well-blooded). Often the tumor sprouts the mucous membrane - then with a biopsy it is possible to establish its morphological structure. Bleeding during biopsy is active.

Xanthoma. The tumor consists of lipofagi. Tumor of a yellowish color. The shape is different, more often incorrectly rounded or oval. Above the surface of the mucous membrane acts slightly. Dimensions from point to 0.6-1.0 cm. When biopsy is actively bleeding.

Bioptate always confirms the morphological structure. Xanthomas on the mucous membrane of the duodenum require special attention. They can be confused with carcinoid, which is more often malignant.

Ectopic pancreas. Always located in the antrum section on the back wall or large curvature, closer to the gatekeeper. External appearance resembles an inflammatory polyp, in contrast to which there is no erosion or fibrotic changes in the flattened apex area. A distinctive feature is the hole in the center of the apex corresponding to the rudimentary duct. When the biopsy forceps grab the apex of the tumor, it freely shifts in the form of a proboscis, released it again retracts to the top of the tumor, without retaining the shape of the proboscis.

Carcinoid. It is a tumor occupying an intermediate place between benign and malignant tumors. Comes from the basal membrane tissue of the mucus-resistant shell. Stained with silver - argentophilic tumor JKT. Has a round or conical shape, the base is wide, delimited from surrounding tissues. The color is usually spotted due to the alternation of whitish-reddish tones. Has a tendency to early erosion and metastasis. The true nature is precisely established on the basis of a biopsy.

Lymphofollicular hyperplasia. Hyperplasia in the lymphoid apparatus of the mucosa or submucosa. Formations of rounded shape on a wide base. Dimensions can be from point to 0.3-0.4 cm. Consistency is dense. The mucosa within the granule is infiltrated. With biopsy, lymphoid and histiocytic infiltration with an admixture of intestinal glands. Color grayish-whitish or grayish-yellowish.

Metastasis of melanoma in the gastric mucosa. They have a round-cylindrical shape, resemble an inflammatory polyp, in contrast to which, in the region of the flattened apex, the mucosa is bluish-smoky or brown in color. With biopsy, bleeding is normal or decreased. Fragmentation is noted. Consistency is dense. The true nature is established on the basis of a biopsy.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]