MRU

At the Focal Point

Ihab I. El Hajj, MD, MPH, Division of Gastroenterology andHepatology, Indiana University School of Medicine, Lei Y. Lim,MD, Leticia P. Luz, MD, Nabil F. Fayad, MD, Division of Gas-

was found incidentally during upper endoscopy screening.

Hde

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edicine, and Section of Gastroenterology and Hepatology,ichard L. Roudebush VA Medical Center, Indianapolis, Indiana,SA

troenterology and Hepatology, Indiana University School of http://dx.doi.org/10.1016/j.gie.2012.12.014

CommentaryRetrograde gastroesophageal intussusception is a rarely reported condition, in which a portion of the stomach invaginatesinto the esophagus. It must be distinguished from retrograde prolapse of the stomach, which is much more common andwhich may resemble at endoscopy its intussusceptive cousin. Gastroesophageal intussusception involves all layers of thestomach, whereas with retrograde prolapse, only the gastric mucosa passes into the esophagus. One predisposing factorinvolves poor fixation of the stomach, often a result of laxity or absence of gastrophrenic, gastrohepatic, gastrosplenic, andgastrocolic ligaments as well as the omental attachments. Other risk factors include increased abdominal pressure duringretching or vomiting, physical exertion as with weight lifting, or ascites. Hiatus hernia with a lax phrenoesophageal ligamentand various operations such as laparoscopic myotomy and fundoplication also have been cited as risk factors. Intussusceptionmay cause intermittent dysphagia, nausea, and abdominal pain in patients with predisposing anatomy. If it is diagnosed in anonemergent setting, it may be reasonable to attempt endoscopic reduction or even gastric fixation, but laparotomy andmanual reduction are usually required.

Lawrence J. Brandt, MD

Associate Editor for Focal Points

Gastritis cystica profunda with a long stalk

A 48-year-old woman was referred to our hospital forevaluation of a long-stalked gastric polypoid lesion, which

er medical history was unremarkable, and she did notescribe having any GI symptoms. The results of physical

xamination were unremarkable. EGD showed a 1.5-cm pol-

olume 77, No. 5 : 2013 GASTROINTESTINAL ENDOSCOPY 821

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At the Focal Point

ypoid lesion with an erythematous head (A) and a longedicle (B). EUS revealed an anechoic lesion with multipleeptae, located superficially to the muscularis mucosa (C).he underwent polypectomy by use of a detachable snare.ross pathologic examination revealed multiple internal cys-

ic portions that were seen on serial sections (D). Microscopicathologic examination showed disruption of the muscularisucosa (arrow) and invaginated cystic glands of varying

izes in the submucosa (E) compatible with gastritis cystica

watery diarrhea that contained fat globules. He did not

del

822 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5 : 2013

ISCLOSURE

All authors disclosed no financial relationships relevanto this publication.

ae Hee Lee, MD, Joon Seong Lee, MD, Institute for Diges-ive Research, Digestive Disease Center, Soonchunhyang Uni-ersity Hospital, So Young Jin, MD, Department of Pathology,oonchunhyang College of Medicine, Seoul, Republic of Korea

rofunda. http://dx.doi.org/10.1016/j.gie.2013.01.004

CommentaryAlthough the condition was first described in 1947 by Scott and Payne, it wasn’t until 1972 that Littler and Glibermannsuggested that the presence of cystically dilated gastric glands in the submucosa was a reactive, postsurgical condition forwhich they coined the term “gastritis cystica polyposa.” Subsequently the preferred term became “gastritis cystica profunda”(GCP) because it resembled the similarly named condition in the colon. The accepted pathogenesis of GCP is thought to berelated to several factors working in concert: something that predisposes to mucosal defects (eg, surgery, biopsy, polypec-tomy), with chronic ischemia and inflammation, all allowing for mucosal prolapse and herniation of glands into the submu-cosa. Although GCP also has been described as a consequence of gastric prolapse and ulcer, it seems that disruption ofmuscularis mucosa integrity is the proximate causation of epithelial migration, regardless of location. As its doppleganger inthe colon, such epithelial misplacement may be superficial (gastritis cystica superficialis) or deep (gastritis cystica profunda),both of which are associated with wide cystic glands. Trauma from torsion of a pedunculated polyp, as in this patient, isthought to induce mechanical disruption at the base of the polyp, promoting the deeper glands to migrate into the submu-cosa. A cuff of normal lamina propria usually surrounds these misplaced glands, with accompanying hemorrhage, and fibrosisin the vicinity of the “misplaced” glands. GCP has been thought to be a precursor of gastric cancer, although the number ofsuch occurrences is small. As in the colon, one must be careful to distinguish the submucosal glands of GCP from invasiveadenocarcinoma. To paraphrase St. Jerome, the scars of others should have taught us diagnostic caution. Careful attention tothe absence of an invasive growth pattern, a lack of cytological atypia, and stromal desmoplasia along with the history ofmultiple diagnostic and surgical procedures help prevent a potential misdiagnosis.

Lawrence J. Brandt, MD

Associate Editor for Focal Points

Endoscopic appearance of duodenal mucosa in Whipple’s disease

A 61-year-old man was seen for weight loss of 20 kgover a 12-month period, mushy stools, and occasional

escribe joint pain or neurologic problems. On physicalxamination, the patient appeared malnourished, with

oss of subcutaneous fat at the triceps, midaxillary line,

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