Varicose veins of the stomach. Malignant tumors of the stomach
Depending on the severity and duration of portal hypertension , the size of varicose trunks and their number may vary. Conventional endoscopic methods are ineffective in stopping bleeding from gastric varicose veins. Some optimism is inspired by the methods of vein injection – the introduction of various drugs into the submucosal layer and the stoppage of bleeding by laser coagulation.
If varicose veins of the stomach are suspected, a routine examination , especially when using endoscopes with end optics, may be ineffective, therefore, an inversion examination of the cardia is mandatory.
Malignant tumors of the stomach . Gastric cancer in childhood is very rare and is usually diagnosed late. The endoscopic picture of gastric cancer in children is no different from the endoscopic picture of advanced gastric cancer in adults. Of the other malignant tumors, lymphomas, reticulosarcomas , leiomyoblastomas , etc. have been described.
Gastric sarcomas are relatively rare. Over 60% of them are lymphomas, about 20% are leiomyosarcomas . Approximately 2/3 of malignant lymphomas of the digestive tract are localized in the stomach. Malignant lymphoma of the stomach can be an independent disease or a manifestation of a systemic lesion. Macroscopically, ED Palmer (1950) distinguishes the following forms of gastric lesions with lymphosarcoma : type 1 – diffuse infiltration with a multi- nodular surface, high and wide folds; type 2 – flattened limited infiltration with nodes slightly rising above it; type 3 – a tumor in the form of a polyp on a stalk or on a wide base; type 4 – ulcerated tumor (progressive ulcer); type 5 – a flattened tumor protruding into the intestinal lumen with flat ulcerations.
R. Schindler (1966) believes that the endoscopic picture of malignant lymphoma is so characteristic that it cannot be confused with anything, although other authors [ Ottenjann R., Classen M., 1979] do not agree with this statement.
Endoscopically , a pronounced infiltration of the submucosal layer is revealed, which deforms the lumen of the stomach or duodenum, making it star-shaped. The organ is poorly spread by air, infiltration occurs in the form of wide longitudinal stripes. The mucous membrane is as if stretched, infiltrated, edematous. It has multiple ulcerations of various shapes and sizes, which may look like longitudinal cracks.
Conventional biopsy does not always allow to confirm the endoscopic diagnosis. In these cases, an extended biopsy is performed in order to obtain material from the submucosal layer for research.
Of particular importance for the prognosis is the differentiation of malignant lymphoblastomas from the so-called pseudolymphomas ( lymphoblastoid gastritis). The endoscopic picture in these two diseases is very similar: there are giant folds with ulceration, limited swelling with an ulcer, pyloric stenosis due to infiltration, a cobblestone relief, etc. Differentiation is carried out on the basis of the results of histological examination of extended biopsies.
Great difficulties may arise in the differential diagnosis of lymphomas and Crohn’s disease with localization in the stomach or duodenum. The main distinguishing feature of Crohn’s disease is longitudinal ulceration (cracks) covered with necrotic and purulent overlays, and the release of creamy pus from these cracks when pressed with biopsy forceps.
A secondary lesion of the stomach of a similar type can occur with plasmacytoma , leukemia, lymphogranulomatosis, metastatic lesions of the stomach.
Often there are significant difficulties in the differential diagnosis of other types of granulomatous gastritis and gastroenteritis: tuberculosis, eosinophilic gastritis and gastroenteritis, other types of hypertrophic gastritis, to which R. Ottenjann (1979) refers to mucosal hyperplasia, Menetrier ‘s disease and glandular hyperplasia in Zollinger-Ellison syndrome . Such lesions in pediatric practice are extremely rare, but can occur, so they should be kept in mind when differentiating tumor-like lesions of the stomach,
Leiomyosarcoma is also rare. At endoscopy, it appears to be a large multinodular neoplasm with ulceration and necrosis of part of the tumor. Extended biopsies should be used for accurate histological identification.