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      An unexpected cause of gastric submucosal lesion Translated title: Uma causa inesperada de lesão submucosal gástrica

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      Einstein

      Instituto Israelita de Ensino e Pesquisa Albert Einstein

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          Abstract

          A 52-year-old asymptomatic patient underwent a follow-up endoscopy for Barrett’s esophagus. His exam showed a 1.5cm bulge in the gastric antrum (Figure 1A). The patient was referred for endoscopic ultrasound, which considered the lesion as a gastrointestinal stromal tumor (Figure 1B), but not a typical one, a computed tomography (CT) of the abdomen was, then, suggested. The CT revealed a heterogeneous lesion involving the gastric antrum and the left lateral segment of the liver (Figure 2A). The exploratory laparotomy revealed the lesion to be a chicken bone (Figure 2B). The postoperative was uneventful except for a suppurative infection on the surgical site. Figure 1 (A) Endoscopy showing a bulge in gastric antrum adjacent to the pylorus. (B) Endoscopic ultrasound revealed the lesion as compatible with a gastrointestinal stromal tumor, but abdominal computed tomography was recommended Figure 2 (A) Abdominal computed tomography showing the lesion involving the stomach and liver. (B) The ingested foreign body: a chicken bone Gastric submucosal lesions are normally mesenchymal in the origin and include gastrointestinal stromal, leiomyomas, leiomyosarcomas, neuroendocrine neoplasms and schwannomas. 1 Endoscopic ultrasound is currently considered the standard approach for evaluating intramural gastric lesions. 2 Gastrointestinal stromal can originate in any part of the gastrointestinal tract. In gastrointestinal stromal (60% of all gastrointestinal stromal tumor), surgical resection is normally recommended. Small tumors (<2cm) with no signs of malignancy (ulceration, bleeding, irregular margin, necrosis and cystic change) can be managed with active surveillance. However, there is potential for malignancy in any gastrointestinal stromal tumor, regardless of size. 1,3-5 Perforation of the digestive tract caused by ingested foreign bodies, on the other hand, is rare. Most of these foreign bodies pass through the digestive tract, and less than 1% of them cause perforation. 6 For unknown reasons, some of them perforate the gastric wall and become lodged at the left lobe of the liver. 7 Removal can be achieved by endoscopy, laparoscopy or laparotomy. It is important to mention that ingestion of foreign bodies often occurs in people who use dental prosthesis, as occurred with our patient. Prostheses hamper oral sensibility. And, they may, not only, be swallowed themselves but also facilitate the act of swallowing some other foreign body. 7,8

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          Most cited references 8

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          Gastrointestinal stromal tumours: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.

          (2014)
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            Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases.

            Ingested foreign bodies (FBs) present a common clinical problem. As the incidence of FBs requiring operative removal varies from 1% to 14%, it was decided to perform this study and compare the data with those from the world literature, as well as to outline an algorithm for management, including indications for surgery. We reviewed all patients with FB ingestion from 1973 to 1993. There were 542 patients with 1203 ingestions, aged 15 to 82 years. Among them, 69. 9% (n = 379) were jail inmates at the time of ingestion, 22.9% (n = 124) had a history of psychosis, and 7.2% (n = 39) were alcoholics or denture-wearing elderly subjects. Most foreign bodies passed spontaneously (75.6%; n = 410). Endoscopic removal was possible in 19. 5% (n = 106) and was not associated with any morbidity. Only 4.8% (n = 26) required surgery. Of the latter, 30.8% (n = 8) had long gastric FBs with no tendency for distal passage and were removed via gastrotomy; 15.4% (n = 4) had thin, sharp FBs, causing perforation; and 53.8% (n = 14) had FBs impacted in the ileocecal region, which were removed via appendicostomy. Conservative approach to FB ingestion is justified, although early endoscopic removal from the stomach is recommended. In cases of failure, surgical removal for gastric FBs longer than 7.0 cm is wise. Thin, sharp FBs require a high index of suspicion because they carry a higher risk for perforation. The ileocecal region is the most common site of impaction. Removal of the FB via appendicostomy is the safest option and should not be delayed more than 48 hours.
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              Soft Tissue Sarcoma, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology.

              Soft tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin that display a heterogenous mix of clinical and pathologic characteristics. STS can develop from fat, muscle, nerves, blood vessels, and other connective tissues. The evaluation and treatment of patients with STS requires a multidisciplinary team with demonstrated expertise in the management of these tumors. The complete NCCN Guidelines for Soft Tissue Sarcoma (available at NCCN.org) provide recommendations for the diagnosis, evaluation, and treatment of extremity/superficial trunk/head and neck STS, as well as intra-abdominal/retroperitoneal STS, gastrointestinal stromal tumor, desmoid tumors, and rhabdomyosarcoma. This manuscript discusses guiding principles for the diagnosis and staging of STS and evidence for treatment modalities that include surgery, radiation, chemoradiation, chemotherapy, and targeted therapy.
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                Author and article information

                Affiliations
                [1 ]Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
                Author notes
                Corresponding author: Rachid Guimarães Nagem – Rua Gonçalves Dias, 332, room 1,001 – Zip code: 30140-090 – Belo Horizonte, MG, Brazil – Phone: (55 31) 3214-0141 – E-mail: rgnagem@ 123456gmail.com
                Journal
                Einstein (Sao Paulo)
                Einstein (Sao Paulo)
                eins
                Einstein
                Instituto Israelita de Ensino e Pesquisa Albert Einstein
                1679-4508
                2317-6385
                Jan-Mar 2017
                Jan-Mar 2017
                : 15
                : 1
                : 112-113
                S1679-45082017AI3772
                10.1590/S1679-45082017AI3772
                5433318
                28444100

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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