CHAPTER 13. POLYPES AND THICKENING OF FOLDED MUCOSA OF THE GASTRIC

1. What are stomach polyps?

Gastric polyps are abnormal growths of epithelial tissue. The mucous membrane around them, as a rule, is not changed. Polyps can have a wide base, or they can have a thin stem. 70-90% of all polyps of the stomach are hyperplastic polyps. The remaining 10-30% is accounted for by adenomatous polyps, glandular polyps of the fundus of the stomach and hamartoma polyps.

2. Describe the histological features of each type of gastric polyp.

Hyperplastic polyps consist of elongated hyperplastic glands of the stomach with a pronounced edematous stroma. Cystic enlargement of the glandular part of the polyps often develops, but without changing the primary cellular structure. Adenomatous polyps are true neoplastic neoplasms from dysplastic epithelium, normally absent in the stomach. Adenomatous polyps consist of cells with hyperchromic elongated nuclei with an increased number of mitoses, arranged in the form of a palisade. Glandular polyps of the fundus of the stomach are hypertrophied glands of the mucous membrane of the fundus of the stomach and are considered a normal variant. Hamartoma polyps have strips of smooth muscle fibers surrounded by glandular epithelium. Own plate (lamina proprid) at the same time remains normal.

3. What is the risk of malignant gastric polyps?

The risk of malignant transformation of hyperplastic polyps is quite low and amounts to 0.6-4.5%. The risk of malignancy of adenomatous polyps as true neoplastic neoplasms depends on the size of the polyps and reaches 75%. Adenomatous polyps larger than 2 cm have an extremely high risk of malignant transformation, although gastric adenocarcinoma can develop from polyps less than 2 cm in size. Glandular polyps of the fundus of the stomach and hamartoma polyps have practically no malignant potential.

4. What is the tactics of treatment for detection of gastric polyps?

Since histological examination of biopsies taken during endoscopy does not always give reliable results, gastric epithelial polyps should, if possible, be completely excised and subjected to thorough histological examination. Gastric epithelial polyps ranging in size from 3 to 5 mm can be completely excised with biopsy forceps. If the size of the polyps - both on a pedicle and on a wide base - reaches more than 5 mm, they are excised using a special loop-trap. All removed tissues are subjected to histological examination. Patients with larger polyps, especially those on a broad base, which cannot be removed using endoscopic techniques, are indicated for surgical treatment. As a rule, hyperplastic and adenomatous polyps occur against the background of chronic gastritis and sometimes intestinal metaplasia. In such cases, the risk of developing stomach cancer is increased regardless of the presence of polyps. With adenomatous polyps of the stomach, the risk of developing cancer is higher than that with hyperplastic polyps. The risk of malignant degeneration of polyps increases with age. Therefore, in all cases, it is necessary not only to remove all polyps, but also to carry out a thorough examination of the entire gastric mucosa. If any suspicious foci are found on its surface, it is imperative to perform a tissue biopsy followed by a histological examination.

5. Is it necessary to carry out dynamic monitoring of patients with gastric polyps?

Patients with hyperplastic polyps and glandular polyps of the fundus of the stomach do not need dynamic observation with regular endoscopic examinations. The recurrence rate of adenomatous polyps is 16%, and although there is no clear benefit from long-term follow-up of such patients, they should be periodically examined and endoscopically examined.

6. What is the relationship between stomach polyps and chronic gastritis?

Adenomatous and hyperplastic polyps of the stomach occur, as a rule, against the background of chronic gastritis and are usually a late manifestation of infection H. pylori or chronic gastritis type A (with pernicious anemia). Multiple mucosal biopsies should be performed to determine the presence and severity of underlying chronic gastritis, focusing on the possible presence and type of intestinal metaplasia. Patients with chronic gastritis and gastric polyps resulting from HP infection should receive specific antibiotic treatment, although it is not known at this time whether eradication H. pylori on the frequency of relapses of a gastric polyp or intestinal metaplasia.

7. What folds of the stomach are considered enlarged?

Enlarged (hypertrophied) folds of the stomach are those folds that do not straighten out during air insufflation during endoscopic examination. X-ray enlarged folds of the stomach are folds, the width of which is more than 10 mm (with fluoroscopy of the stomach with barium suspension).

8. List the diseases in which thickened folds of the stomach are found.

Lymphoma of the stomach.
Syndrome of lymphoid tissue associated with the mucous membrane (MALT-syndrome).
Plastic lignite (linitis plastica).
Adenocarcinoma of the stomach.
Menetrie's disease.
Gastritis caused by H. pylori(spicy).
Zollinger-Ellison Syndrome.
Lymphocytic gastritis.
Eosinophilic gastritis.
Vascular ectasia of the antrum.
Cystic gastritis (gastritis susstica profundo.).
Kaposi's sarcoma (Kaposi).
Varicose veins of the stomach.

9. What systemic diseases cause thickening of the folds of the gastric mucosa (granulomatous gastritis)?

Granulomatous inflammation of the stomach wall occurs in Crohn's disease and sarcoidosis. Other diseases that can potentially lead to granulomatous gastritis include histoplasmosis, candidiasis, actinomycosis, and blastomycosis. Secondary syphilis is sometimes manifested by infiltration of the stomach wall Treponema pallidum, causing a perivascular plasmacytic reaction. Dissemination of mycobacteria in tuberculosis is another cause of infiltrative changes from the side of the stomach wall. With systemic mastocytosis, in addition to facial hyperemia, the development of hyperemia of the gastric mucosa and thickening of its folds is observed. Occasionally, with amyloidosis, gastritis occurs with infiltrative changes and thickening of the folds of the mucous membrane.

10. In endoscopic ultrasound scanning, five different hyper- and hypoechoic layers are distinguished in the stomach wall. What histological layers of the stomach wall do they correspond to?

The structure of the stomach wall (in accordance with the data of ultrasound scanning and histological examination)

LAYERS OF THE STOMACH WALL	ULTRASONIC SCAN DATA	HISTOLOGICAL STUDY DATA
1st	Hyperechoic	Superficial layers of the mucous membrane
2nd	Hypoechoic	Deep layers of the mucous membrane, including its muscle layer
3rd	Hyperechoic	Submucosal layer
4th	Hypoechoic	Muscular membrane
5th	Hyperechoic	Serous membrane

11. What is the role of endoscopic ultrasound in the diagnosis of thickening of the folds of the gastric mucosa?

Although endoscopic ultrasound scanning fails to distinguish between benign and malignant diseases, this method can detect thickening of the mucosal folds, which makes it possible to identify patients who need further examination, consisting either in performing repeated biopsies for endoscopic studies, or in histological examination of the section of the stomach wall excised during the operation. Endoscopic ultrasound scanning is a sensitive method for detecting varicose veins of the esophagus and stomach, which helps to avoid damage during endoscopic biopsy. If endoscopic ultrasound scanning shows limited thickening of the surface layers of the stomach wall, multiple biopsies of the suspicious area should be performed to confirm malignancy. Conversely, if endoscopic ultrasound scans detect thickening of predominantly deep layers of the stomach wall (eg, submucosa or muscularis), endoscopic biopsy may not confirm the diagnosis. Nevertheless, endoscopic ultrasound scanning belongs to the highly sensitive methods of diagnosing malignant neoplasms. To clarify the diagnosis, they often resort to surgery, excision and histological examination of suspicious areas of the stomach wall. In the near future, there will be data on the performance of an aspiration biopsy under the control of endoscopic ultrasound scanning.

12. What are the clinical signs of gastric lymphoma?

Gastric lymphoma occurs in less than 5% of all gastric malignancies. After adenocarcinoma, it is the most common malignant tumor affecting the stomach. Of all primary lymphomas of the gastrointestinal tract, 40-60% are localized in the stomach, 20-30% - in the small intestine, and most often in its ileum. In 8-15% of cases, there is multiple localization of lymphoma. B-cell lymphomas are the largest group of gastric lymphomas, followed by T-cell and other types. On endoscopic examination, lymphomas are found in the form of discrete lipoid growths, ulcerated tumor-like formations, or diffuse submucosal infiltration with enlarged coarse folds of the mucous membrane. The most common clinical symptoms of gastric lymphoma are abdominal pain, weight loss, nausea, lack of appetite, and gastrointestinal bleeding. In cases where there is a suspicion of the presence of gastric lymphoma, and with a conventional biopsy confirmation of the diagnosis is not obtained, it is necessary to perform excision of the tumor site followed by histological examination of the removed tissue, biopsy with a special mesh-trap or aspiration biopsy. When pathological changes are detected in the deep layers of the stomach wall, as well as when regional lymph nodes are damaged, endoscopic ultrasound scanning is of great help. If all attempts to confirm the diagnosis using endoscopic techniques remain unsuccessful, it is necessary to perform a laparotomy, excision of the suspicious section of the stomach wall and its thorough histological examination.

13. Introduce Ann Arbor's classification of non-Hodgkin's lymphomas to gastric lymphomas.

Stage Prevalence of the disease
I Disease confined to the stomach
II Lymph nodes of the abdomen are affected (according to

Biopsy or lymphangiography)

III There are lesions of the stomach, lymph nodes of the abdomen

and lymph nodes above the diaphragm

IV Disseminated lymphoma

14. Give the definition of Menetrie's disease.

Menetrie's disease is a rare disease characterized by the presence of giant, rough folds of the stomach lining. Most often, Menetrie's disease affects the antrum of the stomach. The histological signs of Menetrie's disease are severe hyperplasia and cystic dilatation of the pit epithelium. Hyperplastic changes can also involve the submucosal layer. Clinical symptoms in Menetrie's disease include abdominal pain, weight loss, gastrointestinal bleeding, and hyperalbuminemia. The causes of the development of Menetrie's disease are unknown. The diagnosis of Menetrie's disease can be confirmed by endoscopic ultrasound scanning, when thickening of the deep layers of the mucous membrane is detected, and by histological examination of multiple biopsies, when characteristic changes in the mucous membrane are found. Treatment with histamine H 2 receptor antagonists often gives good results.

15. What is the difference between Menetrie's disease in adults and children?

Unlike Menetrie's disease in adults, which is characterized, as a rule, by a chronic course, in children Menetrie's disease tends to be self-limiting. Relapses and various complications of the disease in children are quite rare. Clinically, Menetrie's disease in children is manifested by sudden attacks of nausea, accompanied by abdominal pain, lack of appetite and hypoproteinemia. Due to the onset of protein-losing enteropathy, edema and ascites gradually appear. Also, hypoalbuminemia often develops, in the peripheral blood - eosinophilia and moderate normochromic, normocytic anemia. X-ray examination reveals a thickening of the folds of the mucous membrane in the area of the fundus and body of the stomach, often extending to the antrum. Hypertrophy of the mucosal folds is confirmed by gastroscopy, endoscopy, and endoscopic ultrasound scanning. On histological examination, mucosal hypertrophy, lengthening of the fossae and atrophy of the glands are observed. In children with Menetrie's disease, histological examination often reveals intranuclear inclusions of cytomegalovirus. When sowing the tissues of the gastric mucosa, cytomegalovirus is also often detected. Symptomatic treatment in children with Menetrie's disease usually has a good therapeutic effect.

16. What is lymphocytic gastritis?

Lymphocytic gastritis is characterized by hyperplasia of the pit epithelium and severe lymphocytic infiltration of the gastric mucosa. (Lymphocytic gastritis is also sometimes called smallpox-like gastritis.) Fibrogastroduodenoscopy reveals thickened, hypertrophied folds of the gastric mucosa, nodular disseminations of the mucous membrane, and multiple erosions, often resembling a volcano crater. The causes of lymphocytic gastritis are unknown. The symptoms of the disease are obliterated and vague; various methods of treatment have no obvious effect. When conducting a clinical examination, it is important first of all to exclude gastric lymphoma or other specific forms of gastritis.

17. What is the role of endoscopic ultrasound scanning in the diagnosis of gastric submucosal neoplasms?

Although endoscopic ultrasound scanning (EUS) does not provide an accurate histological diagnosis, it allows a high degree of certainty to establish the nature of the neoplasm, based on its location and the ultrasound structure of the intestinal wall. With the help of EUS, it is possible to establish the vascular nature of the neoplasm and apply the technique of aspiration cytology and biopsy using special biopsy forceps. Endoscopic ultrasound scanning makes it possible, with a fairly high degree of probability, to differentiate true submucosal tumors from compression of the stomach lumen from the outside. Leuomyomas and leiomyosarcomas are hypoechoic formations emanating from the fourth (hypoechoic) sonographic layer of the stomach wall, which is its muscular layer. According to ultrasonography, there are no fundamental differences in size, shape, and ultrasound structure between LM and LM. Gastric lymphoma is a diffuse hyperechoic formation emanating from the submucosal layer of the stomach wall. Cysts of the gastric wall are detected as anechoic structures in the submucosal layer. Other, much less common neoplasms originating from the submucosal layer, such as accessory pancreas, carcinoid tumors, fibromas and granular cell tumors, do not have any special distinctive ultrasound characteristics. Based on the changes detected during endoscopic ultrasound scanning in the submucous layer of the stomach wall, the doctor determines the tactics of treatment based on the size of the neoplasm. If there is a pathological formation in the submucosal layer less than 2-4 cm in size without signs of bleeding, impaired evacuation from the stomach and malignancy, you can not rush to the operation, but periodically carry out control endoscopic examinations. With the rapid growth of the tumor, surgical treatment is indicated. With the initial detection of a tumor of a larger size, immediate surgery is indicated.

18. What is the differential diagnosis when a submucous pathological formation is detected?

	Most common	Are less common	Rare
	Leiomyoma Lipoma Aberrant pancreas Varicose veins of the stomach	Carcinoid Leiomyosarcoma Granular cell tumor Lymphoma Rudiments of the spleen Submucous cysts Compression of the stomach outside Splenic artery aneurysm	Leiomyoblastoma Liposarcoma Schwannoma

19. During fibrogastroduodenoscopy, a tumor-like formation was revealed in the submucous layer of the stomach. Endoscopic ultrasound scanning revealed a hypoechoic mass originating from the fourth layer of the gastric wall (muscular membrane). What, in your opinion, is the most likely diagnosis for this patient?

The signs found in the patient on endoscopic ultrasound scanning are likely to correspond to those in leiomyoma. Leiomyosarcoma has the same appearance on endoscopic ultrasonograms, although it is much less common. In addition, a similar structure is characteristic of other rare tumors, such as schwannoma, liposarcoma, and myxosarcoma, originating from the muscular membrane of the stomach wall. Endoscopic ultrasound scanning is by no means a substitute for histological tumor verification. The clear boundaries of the tumor, its small size (less than 3 cm), the absence of signs of damage to the surrounding tissues or regional lymph nodes, as well as the unchanged size of the tumor during periodic control studies speak in favor of the benign nature of the disease. In the presence of large tumor-like formations (more than 3-4 cm in size) with a tendency to growth and signs of damage to the surrounding tissues, surgical treatment is indicated.

20. A 65-year-old woman started vomiting with "coffee grounds" contents, which stopped on her own. Endoscopic examination revealed a single 1 cm polyp on a pedicle in the body of the stomach. What should be the treatment tactics?

Most stomach polyps are epithelial in origin. Of these, 70-90% are hyperplastic and 10-20% are adenomatous. Although clinically stomach polyps can present with abdominal pain or gastrointestinal bleeding, about 50% of stomach polyps are asymptomatic. Removal of a polyp during fibrogastroscopy using a special loop-trap with subsequent histological examination of the removed specimen is both a diagnostic and therapeutic measure. Although the risk of complications with endoscopic removal of gastric polyps is higher than with removal of colon polyps during colonoscopy, this procedure is quite safe and well tolerated by patients. To reduce the likelihood of postpolypectomy bleeding, a solution of epinephrine at a dilution of 1:10 000 is injected into the leg of large polyps before resection. To suppress peristaltic movements of the stomach wall and esophagus, which prevent the removal of the drug, glucagon is used. In order to avoid accidentally getting the polyp into the airways during polypectomy, you can place it in a special tube. A short course of histamine or sucralfate H 2 receptor blockers is usually recommended to speed up the healing process, although the benefits of such therapy have not yet been proven.

21. The photo shows a polyp found during fibrogastroduodenoscopy in a patient with familial adenomatous polyposis. What, in your opinion, is the histological structure of this polyp? What is the risk of its malignant transformation? What other important changes in the upper gastrointestinal tract can also be detected with fibrogastroduodenoscopy? What are the clinical manifestations of stomach polyps with other hereditary syndromes accompanied by polyposis of the gastrointestinal tract?

Almost all patients with familial adenomatous polyposis have upper gastrointestinal polyps. In this case, most of the polyps are located in the proximal parts of the stomach or its bottom. Polyps are usually small, multiple, and hyperplastic. Although they practically do not degenerate into adenocarcinoma, they can cause gastrointestinal bleeding. About 40 to 90% of patients with familial adenomatous polyposis have adenomatous polyps in the distal stomach or duodenum, especially in the periampullary region. In residents of the United States with a diagnosed familial adenomatous polyposis, the risk of malignant polyps is not high, while that in Japan tends to increase. Patients with familial adenomatous polyposis and the presence of adenomas in the duodenum and periampullary region have a very high risk of developing duodenal cancer and especially cancer of the periampular region. Patients with Gardner syndrome have predominantly hyperplastic polyps in the proximal stomach. Patients with Peitz-Jeghers syndrome and juvenile polyposis may develop hamartoma polyps in the stomach. Although they are capable of causing gastrointestinal bleeding, the likelihood of their malignant transformation is negligible.

22. What is the relationship between gastric carcinoid tumors and atrophic gastritis?

Carcinoid tumors usually occur in the body and fundus of the stomach. Most often they come from the submucosal layer of its wall, but sometimes they resemble polyps in their appearance. Although carcinoid tumors can be found in the presence of normal mucous membranes, in most cases they appear in patients with atrophic gastritis and achlohydria. Currently, it is believed that carcinoid tumors are formed due to a high concentration of circulating gastrin, which is released as a result of a violation of the innervation of enterochromafin cells in the proximal stomach. Although carcinoid tumors have been found in rats that have been injected with large doses of omeprazole for a long period, nothing of the kind has been found in people who have been receiving therapy that suppress gastric acid secretion for a long time. Treatment of gastric carcinoid tumors that develop against the background of achlohydria and hypergastrinemia consists of antrumectomy in order to remove the source of gastrin production. In the presence of carcinoid tumors that are not caused by hypergastrinemia, it is necessary to perform gastric resection with the removal of large tumors. Approximately 2-3% of all carcinoid tumors in the human body are localized in the stomach. In turn, carcinoid tumors account for only 0.3% of all gastric tumors. Carcinoid tumors of the stomach do not cause clinical symptoms associated with the production of vasoactive peptides, and therefore they are most often detected by chance. Treatment of choice of carcinoid tumors is their complete removal. Many, if not the vast majority, of carcinoid tumors can be removed using endoscopic techniques, either by gradually "nibbling" the tumor pieces with special biopsy forceps, or by means of a special snare loop. If it is planned to perform endoscopic resection of carcinoid tumors, it is necessary to conduct an endoscopic ultrasound scan of the stomach wall in order to clarify from which layer of its wall the tumor originates, as well as the degree and depth of its invasion.

23. Fibrogastroduodenoscopy performed on a homosexual man with acquired immunodeficiency syndrome (AIDS), complaining of abdominal pain, revealed a serpiginous, reddish-lilac thickened fold in the body of the stomach. The patient had similar formations on the hard palate in the mouth and on the lower extremities. What, in your opinion, is this pathological formation? What is the risk of bleeding on biopsy? What can a histological examination of a biopsy material show?

The pathological formation found during endoscopy is most likely a manifestation of Kaposi's sarcoma. Upper gastrointestinal endoscopy or fibrosigmoidoscopy reveals gastrointestinal lesions in 40% of AIDS patients diagnosed with Kaposi's sarcoma of the skin and lymph nodes. Endoscopic manifestations of Kaposi's sarcoma are quite characteristic. The risk of bleeding during biopsy is low. Histological confirmation of the disease is obtained only in 23% of patients, since pathological foci are localized in the submucosal layer. Since vascular lesions are also located deep in the submucosal layer and cannot always be reached with biopsy forceps, biopsy for Kaposi's sarcoma is a safe method, albeit nonspecific. The clinical symptoms of Kaposi's sarcoma are pain, dysphagia, and sometimes gastrointestinal bleeding and intestinal obstruction.

24. A 60-year-old woman complains of nocturnal epigastric pain and secretory diarrhea. Fasting serum gastrin levels are over 1,000 pg / ml. Fibrogastroduodenoscopy revealed diffuse thickening and hyperemia of folds and erosion of the mucous membrane in the antrum of the stomach. A mucosal biopsy was found to be uninformative.
Helicobacter pylori not found in biopsy material. Between what pathological conditions is it necessary to carry out a differential diagnosis? What diagnostic tests should be undertaken next?

Hypergastrinemia occurs for several possible reasons. The absence of a history of operations on the stomach makes it possible to exclude the syndrome of the remaining part of the antrum of the stomach. Taking histamine H 2 receptor blockers or proton pump inhibitors leads to an increase in serum gastrin levels. Atrophic gastritis type A, associated with pernicious anemia, causes the development of hypergastrinemia due to impaired inhibition of gastrin production. Finally, the patient may have hyperplasia of gastrin-producing cells in the antrum of the stomach, or gastrinoma, as a manifestation of Zollinger-Ellison syndrome. Endoscopic manifestations of the gastric mucosa are more consistent with the latter two diseases. If, in the study of the level of gastric secretion, hyperproduction of hydrochloric acid is detected, this will distinguish hypergastrinemia in Zollinger-Ellison syndrome from hypergastrinemia, which developed as a reaction to achlorhydria. Patients with Zollinger-Ellison syndrome do not respond to the administration of exogenous secretin, and serum gastrin levels do not decrease. That is why, when Hypergastrinemia is accompanied by hypersecretion of hydrochloric acid (more than 1,000 pg / ml), a secretin stimulation test must be performed.

25. A 40-year-old man with a history of chronic pancreatitis developed gastrointestinal bleeding that stopped spontaneously. Endoscopy revealed no changes in the esophagus and duodenum. The photograph shows the findings that the endoscopist found in the stomach. What is the most likely diagnosis, in your opinion? What kind of treatment is needed?

The patient has isolated varicose veins of the stomach resulting from splenic vein thrombosis. Splenic vein thrombosis is a potential complication of acute and chronic pancreatitis, pancreatic cancer, lymphoma, trauma and hypercoagulable conditions. Blood flows through the left gastric vein through the splenic vein. In this case, the outflow of venous blood from the esophagus is not disturbed. Due to the fact that endoscopic methods of treatment in most cases do not prevent the development of bleeding from varicose veins of the stomach, splenectomy is necessary for splenic vein thrombosis. Varicose veins of the stomach are localized in the submucosal layer of the stomach wall or in its deeper layers, while varicose veins of the esophagus are located superficially, in lamina propria the mucous membrane of the esophagus. Bleeding from varicose veins of the stomach accounts for 10-20% of all acute bleeding from varicose veins of the gastrointestinal tract. Acute bleeding can be stopped with endoscopic techniques, however, as a rule, repeated bleeding occurs and the mortality rate reaches 55%. When portal hypertension becomes the cause of bleeding, transjugular intrahepatic shunting or surgical treatment with pore-tocaval anastomoses is an effective treatment. The first experiments of European and Canadian surgeons concerning the intravascular administration of cyanoacrylate have yielded fairly good results, but this drug is not currently used in the United States. When bleeding is light, varicose veins of the stomach are difficult to detect among the protruding folds of the mucous membrane. With endoscopic ultrasound scanning, varicose veins of the stomach are revealed in the form of hypoechoic convoluted dilated blood vessels in the submucosal layer of the stomach wall.

26. A 65-year-old woman is examined for iron deficiency anemia and occult blood in her stool. Colonoscopy and fluoroscopy of the stomach revealed no pathology. The photograph shows the findings found in the stomach during fibrogastroscopy. It is necessary on the basis of these findings to make a diagnosis and prescribe the appropriate treatment.

This endoscopic view of the mucous membrane with high sinuous thickened folds, like the spokes of a wheel extending radially from the piloric pulp, covered with easily vulnerable pathologically altered vessels, is characteristic of a condition called "watermelon stomach". Diagnosis is based on endoscopy data. The disease is also called vascular ectasia of the antrum. It is a fairly rare cause of chronic latent gastrointestinal bleeding. The incidence of this disease is not yet known. Vascular ectasia of the antrum of the stomach occurs mainly in women and is often associated with autoimmune diseases or diseases of the connective tissue. Often occurs against the background of atrophic gastritis with hypergastrinemia and pernicious anemia. The pathogenesis of vascular ectasia of the antrum is also unknown to date. Histological examination reveals dilated capillaries of the gastric mucosa with areas of thrombosis, dilated convoluted venous vessels in the submucosal layer of the stomach wall and fibrous hyperplasia of muscle fibers. In chronic blood loss, endoscopic diathermocoagulation of blood vessels is very effective. When using the Nd: YAG laser, the treatment efficiency was higher. The disease may recur, but repeated courses of endoscopic therapy are usually beneficial.

27. What, in your opinion, can be diagnosed when the changes shown in the photo are found in the stomach?

The photo shows the accessory pancreas, which is also called the aberrant, or heterotopic, pancreas. It is usually located in the antrum of the stomach; usually in the center of it there are peculiar depressions. With endoscopic ultrasound scanning, various changes can be detected, but most often a relatively hypoechogenic formation emanating from the mucous membrane or submucosa, in some cases with a duct structure in the center, is detected. The accessory pancreas rarely presents with any clinical symptoms.

The thickness of the stomach wall is more or less constant, regardless of gender and age. Normally, it is 0.5-0.6 cm over the entire area of the organ. However, sometimes thickening may occur, the wall becomes wider, which is an alarming symptom. If this defect occurs, immediate consultation with a specialist is recommended.

General information

Thickening of the walls of the stomach are any deviations upward from the above figures.

The affected area can be different, there are two types of this phenomenon:

limited: the wall of the organ is thickened in a small area, up to 3 cm long. Often accompanied by a change in the relief of the mucous membrane, its rigidity, deterioration of peristalsis up to complete absence;
widespread: a significant part of the stomach wall or the entire surface is covered. Concomitant symptoms: organ deformation, volume decrease, limitation of displacement, cessation of peristalsis.

The presence of even small thickenings is an alarming sign that requires detailed diagnosis. It is difficult to name the exact cause of their appearance: they are symptoms of a wide variety of diseases, including cancer, benign or malignant ones. The exact cause and nature of the disease can be established after examination and biopsy.

EUS for stomach thickening

The main diagnostic method is endoscopic ultrasound. It involves the use of an echoendoscope, at the end of which there are a miniature transducer and a special optical device that allow you to carefully examine the relief of the stomach. Modern equipment has a high resolution, up to 1 mm. Such accuracy is not available with other methods. The effectiveness of the examination is also guaranteed by the use of high-frequency ultrasound, which penetrates into the deepest layers of the mucous membrane.

Indications and contraindications for EUS

However, unlike conventional ultrasound, endoscopic examination has a number of contraindications:

blood clotting disorders;
general serious condition;
the threat of oppression of respiratory and cardiac activity.

They are not a contraindication, but they can complicate the procedure for operations on the upper gastrointestinal tract or stomach, especially fraught with scarring. It is necessary to warn the attending physician about the postoperative period before starting the procedure.

Fibrogastroduodenoscopy

This type of endoscopic examination is another of the most popular. It allows the doctor to visually examine the walls of the stomach and identify possible pathologies. For the procedure, a special device is used - a gastroscope. It consists of a tube with a diameter of 8-11 mm and a length of approximately 100 cm. The front tip is movable, can rotate 180 degrees. There is also a light bulb and a camera for easy inspection.

The probe is used not only for visual diagnostics, but also for biopsy. Microscopic forceps are inserted through the probe to help remove the material.

This procedure is performed if there is a suspicion that the thickening of the walls is associated with cancer. The advantage of fibrogastroduodenoscopy is that it acts in a targeted manner, only the area of interest to the specialist can be affected. The withdrawn sample is transferred for diagnosis, during which the exact cause of the pathology is established.

Thickening as a symptom of stomach inflammation

With the modern rhythm of life, constant stress and improper nutrition, a large part of the population suffers from digestive disorders.

In addition to the above factors, this disease is also influenced by:

frequent drinking;
drug use;
infection;
taking painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs);
autoimmune infection.

In the latter case, inflammation often occurs against the background of other autoimmune diseases, for example, type I diabetes mellitus.

The inflammation is manifested by severe nausea, vomiting, aching pain and heaviness after eating. When these symptoms appear, immediate diagnosis and treatment is required. In the absence of therapy, the disease can provoke a number of complications, one of which is an increase in the walls of the organ, which increases the risk of cancer.

Menetrie's disease: causes and symptoms

This pathology sometimes acts as a cause of the appearance of thickening of the walls of the stomach. It is quite rare, the etiology is not fully understood. A characteristic sign of Menetrie's disease is the formation of folds on the mucous membrane, the thickness of which can reach 2-3 cm. The disease is diagnosed after a number of procedures: blood test, fibrogastroscopy, sometimes X-ray.

Although the exact causes of the disease are unknown, doctors name negative factors that can exacerbate the pathology:

inaccuracies in nutrition;
avitaminosis;
alcoholism;
infectious diseases.

Also, folds on the walls of the stomach can appear due to a benign formation, anomaly or genetic predisposition. A specific factor is chronic lead intoxication.

Against their background, the following can develop:

epigastric pain;
heaviness in the stomach;
increased pain after eating;
vomit;
diarrhea;
stomach bleeding;
sharp weight loss up to 20 kg;
decreased appetite.

Menetrie's disease: treatment

Since the pathology affects the digestive tract, the patient must be prescribed a gentle diet. Its main component is protein. It is required to remove fried and spicy foods from the menu, as well as not to eat hot or cold foods.

Drug therapy consists of taking:

enveloping, astringent drugs that protect the walls of the stomach from negative influences;
drugs to compensate for the deficiency of acid-forming function;
atropine, which reduces protein loss and improves well-being.

If the disease is severe: with bleeding, severe pain, surgical treatment will be required.

A gastrectomy is performed, that is, the removal of the stomach. After this procedure, the patient is constantly monitored by a doctor, visits FGDS every six months.

Thickening of the mucous membrane as a symptom of stomach cancer

In serious cases, this pathology is a symptom of cancer. A biopsy performed during EGD will help to accurately establish this fact. The specialist also determines the stage of the disease: stomach cancer develops gradually, at the zero stage there are no symptoms, at the first stage, a slight malaise is found.

The method of treatment is determined according to the nature of the disease.

immunoglobulins "recognize" foreign cells and activate natural immunity to fight them;
enzyme inhibitors penetrate cancer cells, destroying them from the inside.

Radiation and chemotherapy are also used. In critical situations, surgical treatment is recommended: the walls of the stomach or the entire organ are excised.

To reduce harm to the body, it is required to seek treatment immediately after the detection of pathology.

Thickening of the stomach walls

Asks: Ekaterina, Ust-Labinsk

Gender: Male

Age: 5

Chronic diseases: No.

Hello good afternoon!
I decided to examine my son so as not to miss any sore (we had a norovirus infection, and vomiting, I was afraid that there was a problem with my stomach). They did an ultrasound scan, set indirect signs of gastritis. The walls, at a rate of 6 mm, we have 12 mm (as the ultrasound doctor said). Said the stomach "glows" like a New Year tree (suggested Helicobacter). A lot of mucus (because of this we were told there may be poor appetite, fast satiety). In general, the child feels normal, there are no complaints and there have never been any stomach or gastrointestinal complaints. With all this, we went to the pediatrician, got tested for Ascaris, Helicobacter, Toxocar, Toxoplasma, Giardia - nothing. Nevertheless, there are increased eosinophils in the blood - the doctor said at a rate of 0.1, we have 14 (or did not specify 0.14). For the stomach I prescribed Omez (1 capsule. On an empty stomach, Acipol 3 r. A day, Pancreatin - 0.5 tab. 3 times a day after meals.) We did it all, he also has no complaints, his appetite is bad, wow. It was always difficult to force me to eat, now by persuasion and fear of the hospital, I try to force me to eat often, little by little. Weighs at 5 years old - 15.5 kg. Height 107 cm.
Tell us your opinion - were we prescribed adequate treatment? I know that it would be good to do a gastroscopy, but I know that I will not force my son to do it on a bright head. (we donate blood from a finger - we keep it together with my husband, I myself cannot hold him), but I don’t want anesthesia. Could there be such a change in the stomach due to antibiotics? This year we have already been in bed three times (after kindergarten), three times we received courses of antibiotics (1 time 10 days, the second time 10 days, the third time 5 days). He never had an allergy, my husband and I, too, even in our closest relatives there are no allergy sufferers. What, then, are eosinophils elevated? And what are the predictions with our stomach? I don’t want to feed me with medications, but most of all I’m afraid of wasting time and making it chronic. Thank you in advance!

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Catherine! Was the rotavirus infection confirmed by a rota test? In the instructions for the drug Omez, there are indications that it is not prescribed in childhood. What medications did the child take to treat rotavirus infection? The use of antibiotics does not affect the thickening of the stomach wall.

Catherine 2015-09-04 08:32

We had a norovirus infection. We went to the hospital with her, at discharge the infectious disease doctor told us that we had her. Because of this, there was vomiting. Tests were not performed, blood, scrapings and feces were taken. Since the blood in the hospital was inflammatory, he was injected with ceftriaxone, and from the drugs he took Pancreatin and Acipol. After the ultrasound, the local pediatrician prescribed Omez to us, she said that since there are indirect signs of gastritis, then it is necessary to treat them. After taking the first capsule, the child has a red rash after the nose. I didn’t give more Omez. Only Acipol and Pancreatin. Now I don’t give anything. I plan to do another ultrasound scan to see how things are now. I would like to hear your advice on our affairs. What should be done, or is there no need for some kind of treatment? Thanks in advance!

Catherine! The virus can only be detected by the PCR reaction of Norovirus. Only then can we say that the child has suffered this infection. It passes quickly. Only this virus has the ability, when it enters the body, to join the cells of the gastrointestinal tract. With a viral infection, the blood is never inflammatory, since viruses cause a decrease in the number of leukocytes. Ceftriaxone was used to reduce the development of pathogenic flora that might be in the intestines. Antiviral drugs had to be added. For the diet, foods such as rice, bread, bananas, applesauce, pasta, and clear liquids are offered. The food is warm and steamy. For gastritis, use a decoction of chamomile pharmacy. Leave Mezim-Forte taking before meals, Linex capsules. The course is 7 days. The symptoms of gastritis should go away with time. Do not take omez.

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Stomach cancer is a malignant tumor that develops from the epithelium. In this article, we will tell you about the symptoms of stomach cancer and the signs of stomach cancer.

Prevalence of stomach cancer

In terms of morbidity and mortality in Russia, stomach cancer ranks second among malignant neoplasms (incidence is 40 in the population). Signs appear in men about 2 times more often. The peak incidence occurs at age.

Stomach cancer symptoms

What are the symptoms of stomach cancer?

The course of stomach cancer also depends on the form of growth of the tumor itself. Symptoms of exophytic cancer growing into the lumen of the stomach produce scant local symptoms. Often, bleeding is the first manifestation of it. With endophytic cancer, for a long time, patients are concerned only with symptoms of a violation of the general condition (weakness, pallor, anorexia, weight loss). As the tumor grows, symptoms appear, depending on its location.

Cancer of the pyloric region is characterized by signs of impaired patency: rapid satiety, a feeling of fullness in the epigastrium, and subsequently vomiting of eaten food. For cancer of the cardiac region, symptoms are characteristic - increasing dysphagia, chest pain, regurgitation. The defeat of the body of the stomach proceeds latently, and often the initial symptoms of the disease are a violation of the general condition: signs - weakness, decreased appetite, weight loss, a feeling of heaviness in the epigastric region.

Often, it is in the antrum that the primary ulcerative form of stomach cancer symptoms develops, which is manifested by signs of an ulcer-like syndrome - "hungry" late night pains. As with some other solid tumors (kidney cancer, bronchogenic cancer, cancer of the pancreas, colon), signs of paraneoplastic syndrome may develop - arthralgia, hemorrhagic vasculitis, thrombosis.

Signs of stomach cancer

Clinical signs of cancer manifestation are nonspecific and diverse (in 60% of patients, stomach cancer is detected during examination for other diseases or during a routine examination). Patients are usually worried about symptoms such as unreasonable discomfort and pain in the epigastric region. A decrease in body weight is noted by 80% of patients, rapid satiety with food - 65%, anorexia - 60%. Dysphagia and vomiting occur in 50% of patients. Physical examination findings usually indicate an advanced stage of the disease. This is a palpable tumor in the epigastrium, jaundice, hepatomegaly (palpable nodes in the liver), ascites, cachexia, Virchow's metastasis (typical for gastric cancer enlargement of lymph nodes in the supraclavicular region on the left). When rectal examination in the rectovaginal (rectovesical) fossa, Schnitzper's metastasis is found. Depending on the predominance of certain symptoms in the clinical picture, several clinical variants of the course of gastric cancer are distinguished.

A febrile variant occurs when there are signs of infection of a peptic ulcer and / or in the presence of severe tumor intoxication. Fever is subfebrile, but sometimes the body temperature rises to 39-40 ° C with a maximum rise in the morning; symptoms are resistant to antibiotics.
The edematous variant (edema occurs as a result of hypoproteinemia) develops with prolonged malnutrition.
The icteric variant occurs with symptoms of stomach cancer with increased hemolysis or toxic hepatitis as a result of exposure to tumor decay products, but more often it is a consequence of metastatic liver damage.
Hemorrhagic (anemic) variant of stomach cancer develops with prolonged latent bleeding. With metastatic lesions of the bone marrow, along with anemia, leukocytosis may occur with the appearance of myelocytes and myeloblasts in the peripheral blood.
The tetanic variant occurs with symptoms of pyloric stenosis.
The intestinal variant is accompanied by symptoms of constipation or diarrhea.

Classification of stomach cancer

There are various classifications of gastric cancer based on clinical symptoms, morphological signs, endoscopic data. International TNM classification of stomach cancer (tumor - primary tumor, modulus - damage to regional lymph nodes, metastasis - distant metastases) is based on determining the extent of the tumor process. At present, it is customary to separately isolate the symptoms of early gastric cancer (signs - a small tumor with a diameter of up to 3 cm, located within the mucous and submucosal membranes, without penetration into the muscular membrane of the stomach wall and without metastases, corresponds to TiN0M0), characterized by a good prognosis (after resection stomach five-year survival rate is 95%).

Causes of stomach cancer

The cause of stomach cancer is unknown. The factors predisposing to the development of stomach cancer are diverse, they are divided into exogenous and endogenous.

Exogenous factors of stomach cancer

Carcinogens. The risk of developing cancer symptoms increases with frequent consumption of foods containing various preservatives, nitrates. It is not nitrates themselves that have carcinogenic properties, but their derivatives (nitrites, nitrosamines, nitrosamides), which form nitrate-reducing bacteria at low gastric acidity (pH 5.0 and higher). It is known that ascorbic acid is an antagonist of these compounds.

Helicobacter. Cancer symptoms often develop against the background of chronic gastritis associated with Helicobacter pylori. Atrophy and dysplasia occurring against this background are considered as symptoms of precancerous diseases. In 1994, the International Agency for Research on Cancer at WHO classified H. pylori as a class I carcinogen for humans.

Endogenous factors of stomach cancer

Stomach ulcer. It is assumed that the stomach ulcer, against the background of which the symptoms of cancer subsequently develop, is already initially a cancer of the stomach of the ulcerative form. Its difference from a "benign" ulcer is poor healing with adequate antiulcer therapy.
Postponed surgery for symptoms of gastric ulcer (the risk increases by about 2.4 times).
Dysplasia of the epithelium of a high degree, especially of the intestinal type (as a rule, it develops with signs of bile reflux from the duodenum). Incomplete intestinal metaplasia is especially dangerous.
Vitamin B12-deficiency anemia, primary and secondary immunodeficiencies, Menetrie's disease, adenomatosis, chronic atrophic gastritis with achlorhydria.

Forms of stomach cancer

Highly differentiated adenocarcinomas usually develop slowly and metastasize late. Poorly differentiated forms of stomach cancer are more malignant symptoms: they metastasize earlier, and are less responsive to treatment.

Macromorphology of stomach cancer symptoms

Exophytic tumors usually grow in the lumen of the stomach and are delimited from healthy tissue. Such growth is less malignant.

Symptoms of a polypoid tumor (3-10% of cases) are often localized on the lesser curvature and usually has the form of a mushroom cap located on a broad base, or a polyp on a long stem of purple color with a surface covered with erosions and fibrin deposits. The mucous membrane around the tumor is not changed. Its size is very variable - from a few millimeters to a giant tumor that occupies the entire lumen of the stomach.

Saucer-shaped (cup-shaped) cancer is a tumor on a broad base, with disintegration in the center, in the form of an ulcer with high roller-like edges, consisting of tumor tissue. The bottom of the cancerous ulcer is uneven, covered with a dirty gray or dark brown coating. Blood clots and thrombosed vessels can be seen in the ulcer crater. The tumor is sharply delimited from healthy tissue with symptoms of stomach cancer. If the tumor is located on the lesser curvature, it can acquire an infiltrative growth.

Plaque stomach cancer is a rare form (1% of cases). Macroscopically, it is a whitish or grayish thickening of the mucous membrane up to 1-2 cm in diameter, sometimes with ulceration.

Endophytic tumors, growing, capture the adjacent sections of the stomach wall, infiltrating and spreading along them in all directions. It is a deep ulcer with a dense, bumpy bottom. The size of the ulcer for stomach cancer symptoms is very variable. The areas surrounding the ulcer are infiltrated by tumor tissue, which grows through all layers of the stomach wall and adjacent organs. The wall of the stomach is thickened, hardened. Around the tumor, the mucous membrane is atrophic, rigid, without normal folds. A tumor with symptoms of stomach cancer is most often localized in the outlet section of the stomach, on the lesser curvature and in the subcardial section. Gives early metastases.

Diffuse fibrous gastric cancer (skirr) ranks second in frequency and accounts for 25-30% of all forms of gastric cancer. It is more often localized in the outlet section, narrowing it circularly and spreading to the entire stomach, significantly reducing its size. The wall of the stomach is thickened, rigid. The folds of the mucous membrane with symptoms of stomach cancer are also thickened, with multiple ulcerations. Infiltration can capture the ligaments of the stomach, as a result of which it is pulled up to the liver, posterior abdominal wall, pancreas, etc. Symptoms of cancerous lymphangitis often develop.

Diffuse colloid stomach cancer is a rare type of tumor that spreads mainly in the submucosal layer or between layers of the muscle membrane in the form of layers of mucous masses formed from cells containing mucus. The wall of the stomach is significantly thickened, mucus flows out of it on the cut. The stomach can be greatly enlarged. This is a symptom of the disease.

In about 10-15% of cases, there are signs of mixed or transitional forms of the tumor.

Metastasis of gastric cancer

Stomach cancer metastasizes in three ways: lymphogenous, hematogenous, implantation. The most typical signs of metastases are Virchow, Schnitzler, Krukenberg. The lymphogenous pathway is the most common with symptoms of stomach cancer. Cancer cells enter the lymphatic vessels during their germination or from interstitial spaces.

The hematogenous pathway is possible if the tumor invades the lumen of the blood vessels. In this case, most often, tumor cells enter the liver. Implant metastasis. When a tumor grows into the serous membrane of the stomach with symptoms of stomach cancer, tumor cells are exfoliated from its surface. Once in the lumen of the abdominal cavity, they can settle on the parietal or visceral peritoneum.

Diagnosis of stomach cancer

Radiography for stomach cancer

Correctly performed X-ray examination suggests the presence of symptoms of early stage gastric cancer in 40% of patients. The most important radiological signs of early cancer are as follows:

Areas of restructuring of the relief of the mucous membrane, limited in area, with thickening and chaotic arrangement of folds or persistent thickening of at least one of them.
Symptoms of flattening of the folds of the mucous membrane in a small area, unevenness, roughness, jaggedness of the contour of the stomach.

In late stages, exophytic forms of gastric cancer are characterized by a symptom of a marginal or central (less often) filling defect ("plus-tissue"): its contours are lumpy, folds suitable for the tumor break off at its base. The tumor is clearly demarcated from the unchanged mucous membrane. A characteristic symptom of saucer-shaped stomach cancer (with the disintegration of an exophytic tumor) is the presence of a barium depot in the center of the filling defect ("minus tissue").

For endophytic cancer, due to the peculiarities of growth, the study of changes in the relief of the mucous membrane with symptoms of stomach cancer is of particular importance. Characteristic features: absence of folds, deformation of the stomach in the form of a circular narrowing of the outlet section, shortening of the lesser curvature, unbentness of its angle, a decrease in the internal dimensions of the stomach (at later stages).

Endoscopic diagnosis is the most informative, as it allows you to obtain a biopsy material to confirm the diagnosis of symptoms of stomach cancer. A protruding cancer includes signs of exophytic polypoid neoplasms 0.5-2 cm in size with an unexpressed or short stem, a wide base, a flat or retracted apex.

Elevated cancer is a symptom of a formation that rises 3-5 mm above the surface of the mucous membrane in the form of a plateau with areas of necrosis and depressions.

Squamous gastric cancer has the appearance of a compacted area of the mucous membrane of a rounded shape, devoid of the typical relief of the mucous membrane.

Deep stomach cancer is visually characterized by clearly defined flat erosive fields with uneven edges, located slightly below the level of the mucous membrane. In the lesion, there are no signs of shine, characteristic of a normal mucous membrane.

Symptoms of concave cancer is a defect of the mucous membrane with a diameter of up to 1-3 cm with unevenly thickened rigid edges protruding above the surface of the mucous membrane, and an uneven bottom, the depth of which can be more than 5 mm.

Visual diagnosis of early symptoms of stomach cancer and their differential diagnosis with benign polyps and ulcers are very difficult, therefore additional research methods (biopsy, chromogastroscopy) must be used. Chromogastroscopy - detection of early gastric cancer by studying the intrinsic and tetracycline luminescence of the tumor, determined by gastroscopy and biopsy specimens. In the area of a malignant tumor and in the presence of cancer elements in biopsy specimens, the intensity of its own luminescence decreases and the luminescence increases after administration of tetracycline due to the ability of tumor cells to accumulate it. The final diagnosis of early gastric cancer is possible only on the basis of data from the morphological examination of the material of multiple biopsies.

Symptoms of polypoid cancer are a clearly delineated exophytic growing tumor with a wide base, smooth, bumpy or nodular surface.

Signs of a non-infiltrative cancer ulcer (saucer-shaped cancer) looks like a large deep ulcer with a diameter of 2-4 cm, clearly delimited from the surrounding tissue, with uneven edges.

An infiltrative cancer ulcer has signs of indistinct edges, which are absent in some places, and its tuberous bottom directly passes into the surrounding mucous membrane. The folds of the mucous membrane around the ulcer are rigid, wide, low, do not straighten when air is pumped, peristaltic waves are not traced. The border between the edges of the ulcer and the surrounding mucous membrane is absent. Often, the contours of the ulcer crater are difficult to outline due to the rough bottom topography. In such cases, the symptoms of an infiltrative cancer ulcer are presented in the form of several defects, not sharply delimited from each other, located on the cancerous mass. An infiltrative cancer ulcer leads to a gross deformation of the stomach.

Diffuse infiltrative cancer. It is characterized by symptoms of submucosal tumor growth, which complicates its endoscopic diagnosis. When the mucous membrane is involved in the process, a typical endoscopic picture of a "malignant" relief develops: the affected area swells somewhat, the folds are motionless, "frozen", they are poorly straightened when air is pumped, peristalsis is reduced or absent, the mucous membrane is "lifeless", has a predominantly gray color.

In cases of infection and the development of symptoms of inflammation, infiltrative cancer is visually difficult to differentiate from the local form of superficial gastritis and benign ulceration, especially in the proximal stomach. This should always be borne in mind and biopsies of all acute ulcerations. Histological and cytological examination of biopsy material is crucial in establishing the final diagnosis of gastric cancer and its morphological type.

Endosonography for gastric cancer

Endosonography allows you to determine the depth of infiltration of the stomach wall.

Ultrasound and CT scan for stomach cancer

Ultrasound and CT scan of the abdominal cavity and small pelvis with symptoms of stomach cancer. A frequent finding is signs of liver metastases and Krukenberg metastasis (to the ovary). The metastatic origin of these formations can only be proved by histological examination (biopsy) during surgical intervention (diagnostic laparotomy and laparoscopy). Upon confirmation of their malignant nature, the stage of gastric cancer is defined as IV (Mi).

Symptoms of anemia due to chronic blood loss and toxic effects of tumor metabolites on the red bone marrow are observed in 60-85% of patients. In 50-90% of cases, the reaction to occult blood in the stool is positive. The gastric contents are examined for increased beta-glucuronidase activity and acidity levels for symptoms of gastric cancer.

Differential diagnosis of stomach cancer symptoms

Stomach cancer must be differentiated from gastric ulcer and benign stomach tumors (polyps, etc.). In all cases, only targeted gastrobiopsy can finally confirm the diagnosis of stomach cancer.

The following signs suggest stomach cancer:

The main symptom is the unevenness of the edges of the ulcer with undermining of one and the elevation and "creeping" of the other edge.
Irregular shape (amoeba-like).
Granularity of the mucous membrane around the ulcer, thickening of the mucous membrane.
The edges of the ulcer are sometimes bright red in color, resembling in appearance fresh granulations with symptoms of stomach cancer.
The mucous membrane around the cancer ulcer is flaccid, pale, loose, bleeding.
The bottom is relatively flat, shallow, gray, granular.
An additional symptom is ulceration of the edges of the ulcer.
The base of the malignant ulceration is rigid, and the folds of the mucous membrane converge to one of the edges - the main symptom.
Multiple targeted gastrobiopsy is shown, and tissue samples should be taken both from the edge of such an ulcer and from its bottom.

Symptoms of polyps and stomach cancer

Polypoid stomach cancer has symptoms - significant size (at least 2 cm), a wide base, passing into the surrounding mucous membrane. At the top of such an education, there may be erosion, hemorrhage, edema, necrosis, i.e. signs of its destruction. The small size of the polyp, the narrow base, the juiciness of the undisturbed mucous membrane usually indicate the benign nature of the tumor. Most of them are hyperplastic polyps. However, one should take into account the high incidence of malignancy of adenomatous polyps (up to 40%). Therefore, polyps with a wide base and more than 2 cm in size should be removed with subsequent examination of their morphology.

Other tumors and symptoms of stomach cancer

Other benign tumors (leiomyoma, xanthoma) are rare. The main signs of a benign tumor are undisturbed mucous membrane, gastric motility is preserved, folding is pronounced, the color of the mucous membrane is not changed (except for xanthoma, it has a pronounced yellow color).

Thickened folds of the stomach

Another question is that since they began to fight Helicobacter in earnest, this infection has changed a lot and a large number of strains with various drug resistance have long appeared.

And now, in order to carry out effective eradication, it is often very little to prescribe standard means against Helicobacter in the standard way, which was usually enough years ago. Let's face it - this is beyond the competence of an ordinary therapist, you need a gastroenterologist.

Look for another specialist.

But according to the description of the FGS, this is not so obvious. No wonder the endoscopist wrote such a conclusion with a question mark.

Without knowing the qualifications of your specialists (endoscopist and cytologist), it is impossible to say unequivocally whether there is actually a polyp there or not.

But if we are talking about a hyperplastic polyp (and in fact - a false one), then just anti-Helicobacter and anti-inflammatory treatment in the aggregate can easily lead to the disappearance of such "growths".

And I will even predict that after such treatment and eradication your "polypoid fold" with a high degree of probability will disappear without a trace. Unless, of course, there is a true polyp. But even if there is, then after treatment and diagnosis it will become much more accurate, and it will not be too late to carry out a polypectomy if necessary, and carrying out this manipulation in conditions of subsided inflammation is still much better than in its midst.

What does the thickening of the stomach walls indicate?

General information

Thickening of the walls of the stomach are any deviations upward from the above figures.

The affected area can be different, there are two types of this phenomenon:

limited: the wall of the organ is thickened in a small area, up to 3 cm long. Often accompanied by a change in the relief of the mucous membrane, its rigidity, deterioration of peristalsis up to complete absence;
widespread: a significant part of the stomach wall or the entire surface is covered. Concomitant symptoms: organ deformation, volume decrease, limitation of displacement, cessation of peristalsis.

EUS for stomach thickening

Indications and contraindications for EUS

However, unlike conventional ultrasound, endoscopic examination has a number of contraindications:

blood clotting disorders;
general serious condition;
the threat of oppression of respiratory and cardiac activity.

Fibrogastroduodenoscopy

The probe is used not only for visual diagnostics, but also for biopsy. Microscopic forceps are inserted through the probe to help remove the material.

This procedure is performed if there is a suspicion that the thickening of the walls is associated with cancer. The advantage of fibrogastroduodenoscopy is that it acts in a targeted manner, only the area of interest to the specialist can be affected. The withdrawn sample is transferred for diagnosis, during which the exact cause of the pathology is established.

Thickening as a symptom of stomach inflammation

With the modern rhythm of life, constant stress and improper nutrition, a large part of the population suffers from digestive disorders.

In addition to the above factors, this disease is also influenced by:

frequent drinking;
drug use;
infection;
taking painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs);
autoimmune infection.

In the latter case, inflammation often occurs against the background of other autoimmune diseases, for example, type I diabetes mellitus.

Menetrie's disease: causes and symptoms

Although the exact causes of the disease are unknown, doctors name negative factors that can exacerbate the pathology:

inaccuracies in nutrition;
avitaminosis;
alcoholism;
infectious diseases.

Also, folds on the walls of the stomach can appear due to a benign formation, anomaly or genetic predisposition. A specific factor is chronic lead intoxication.

Against their background, the following can develop:

epigastric pain;
heaviness in the stomach;
increased pain after eating;
vomit;
diarrhea;
stomach bleeding;
sharp weight loss up to 20 kg;
decreased appetite.

Menetrie's disease: treatment

Drug therapy consists of taking:

enveloping, astringent drugs that protect the walls of the stomach from negative influences;
drugs to compensate for the deficiency of acid-forming function;
atropine, which reduces protein loss and improves well-being.

If the disease is severe: with bleeding, severe pain, surgical treatment will be required.

A gastrectomy is performed, that is, the removal of the stomach. After this procedure, the patient is constantly monitored by a doctor, visits FGDS every six months.

Thickening of the mucous membrane as a symptom of stomach cancer

The method of treatment is determined according to the nature of the disease.

immunoglobulins "recognize" foreign cells and activate natural immunity to fight them;
enzyme inhibitors penetrate cancer cells, destroying them from the inside.

Radiation and chemotherapy are also used. In critical situations, surgical treatment is recommended: the walls of the stomach or the entire organ are excised.

To reduce harm to the body, it is required to seek treatment immediately after the detection of pathology.

7.2.4.3. Changes in the stomach with certain diseases

Chronic gastritis is a widespread disease. Distinguish between superficial and atrophic chronic gastritis. Superficial gastritis can be focal and diffuse. This gastritis is reversible. It takes 15–20 years for atrophic gastritis to develop.

According to the mechanism of development, chronic atrophic gastritis is divided into types A, B and AB.

Type A gastritis is autoimmune, characterized by an early onset of atrophic processes and damage mainly to the fundus of the stomach.

Type B gastritis is bacterial, the most common (about 80% of all cases). It affects primarily the antrum of the stomach at first, and then spreads along the lesser curvature in the cardiac direction.

Type AB gastritis is a mixed form of chronic gastritis, which has symptoms of both autoimmune and bacterial gastritis.

X-ray functional signs of chronic gastritis include hypersecretion, change in tone; persistent deformation of the pyloric part of the stomach, disturbance of peristalsis, etc. In the diagnosis of such gastritis, the study of the microrelief of the mucous membrane is of decisive importance.

So, with superficial gastritis, there is a gentle uniform pattern of areoles of an irregularly rounded or polygonal shape, with an average diameter of 2–5 mm, delimited from each other by very thin barium grooves. If the glands are affected, then there is a uniform thorny pattern due to the large height of the areoles, rounded or oval in shape, measuring from 3 to 5 mm, sometimes located in the form of a palisade.

With atrophic gastritis, a rough uneven pattern of gastric fields of various shapes and sizes is noted (the maximum diameter of the areoles is more than 5 mm), similar in some cases to the picture of polypoid formations. Small scarring of the greater curvature of the outlet section of the stomach is typical, due to the tangential image of enlarged areoles.

If the inflammatory process is localized in the distal third of the stomach (antrum), then this part of the organ is deformed, the relief of its mucous membrane changes, and peristalsis is disturbed. The late stage of this gastritis is characterized by secretory insufficiency, the disappearance and compaction of the pylorus, sclerosis of the submucosa, and the development of rigid antral gastritis.

A type of chronic process is gastritis with erosions of the gastric mucosa, manifested by symptoms of gastrointestinal bleeding. On the gastric mucosa, multiple barium depots are found, surrounded by an inflammatory shaft.

Anastomositis - inflammation in the area of artificially imposed anastomosis, mainly of the digestive tract. Common after gastric surgery. It is manifested by inflammatory infiltration of the stomach wall in the area of the anastomosis.

The folds of the mucosa sharply thicken, poly-like and pillow-like eminences appear, the anastomosis narrows, its patency is disturbed, which is accompanied by a delay in the evacuation of the contrast agent from the stomach stump. A large sac-shaped stump with a wide and low horizontal level of barium suspension is revealed. Narrowing of the anastomosis is also observed in the late postoperative period, more often after gastrectomy, as a result of inflammation with subsequent scarring.

Acute stomach ulcer is characterized by a predominance of exudation and necrosis processes, the zone of which is not clearly delimited from healthy tissues.

The niche is usually small in size, round, triangular or oval in shape with a pronounced inflammatory shaft around. Sometimes the shaft blocks the entrance to the ulcerative crater and a filling defect may form in the affected area.

Chronic gastric ulcer (Figures 53, 54) is characterized by the predominance of productive processes, growth of granulation and connective tissue in its edges and bottom, clearly distinguishing between the affected and healthy tissues.

X-ray examination shows large niches and scarring around. If the ulcer is located in the pylorus, symmetric contractions of the base of the bulb, elongation and angularity of it, the picture of an hourglass in the antropylorobulbar region are determined, less often - inflammatory hypertrophy of the pyloric canal. A cicatricial ulcer of the pyloric canal often looks like a stellate contrast spot with radiantly diverging folds of the mucous membrane. With a large cicatricial deformity of the pyloric canal with the formation of several pockets, significant diagnostic difficulties arise. In some cases, the ulcer is mistakenly regarded as a pocket; in others, some of the pockets mimic an ulcer. In the ulcerative niche, in contrast to the cicatricial pocket, folds of the mucous membrane are not visible. The contours of the ulcer are clearer and more even, the shape is correct. A cicatricial pocket is a less stable formation, its shape and size change depending on the contraction of the gatekeeper, and most importantly, folds of the mucous membrane are always visible in it (especially on pneumorelief).

A penetrating stomach ulcer (Figures 54, 55) is characterized by the destruction of all layers of the wall of the affected organ and damage to the adjacent organ with the formation of a canal that does not communicate with the abdominal cavity.

The niche penetrates far beyond the contour of the stomach. In this case, a symptom of two or even three layers often appears: the lower layer is barium suspension, the middle layer is liquid, and the upper layer is gas. The edges of the niche are undermined, the diameter of the entrance to it is less than the diameter of the ulcerative crater itself, the inflammatory shaft is well pronounced. After gastric emptying, residues of contrast medium remain next to the shadow of the stomach wall. When the ulcer penetrates into a nearby hollow organ, a channel is determined through which the contrast agent enters this organ.

A perforated gastric ulcer is characterized by the destruction of the organ wall throughout its entire thickness with the formation of a channel that communicates the cavity or lumen of the affected organ with the adjacent abdominal cavity.

RI: manifested by the presence of free gas and liquid in the abdominal cavity, high standing and limited mobility of the left dome of the diaphragm. A uniform darkening of the left subphrenic region is possible due to the greatest accumulation of fluid near the rupture site. In this case, the contours of the spleen and liver may be absent or indistinct. The loops of the small intestine are moderately distended.

Polyps of the stomach (Fig. 56) are single and multiple, mainly in the antrum of the stomach. They are located either on a wide base or on a leg of various lengths, which determines their some mobility. Distinguish between adenomatous and hyperplastic polyps.

Adenomatous polyps are characterized by round or oval filling defects with clear, even contours and the appearance of a ring symptom.

Hyperplastic polyps also give filling defects, which are located along the thickened folds of the mucous membrane, their diameter does not exceed 1 cm. The contours of the polyps are clear, the “ring” symptom is absent.

In all cases, the folds of the mucous membrane remain. They go around the filling defect. Peristalsis of the stomach is normal.

With malignant polyps, a persistent depot of barium suspension is found in the area of the filling defect, which has a regular-rounded shape. An increase in the polyp is noticeable in a relatively short period of time, it is often asymmetric. Uneven tuberosity appears, an inhomogeneity of an additional shadow against the background of air due to separate denser areas, an irregular shape of the polyp. The symptom of the backstage is noted when the popip is located on the contour, the unevenness of the base of the polyp and the adjacent adjacent walls of the intestine (indicates the invasiveness of growth). Important symptoms are a sufficient variability in the shape of the polyp with a change in intragastric pressure, the marginal location of the polyp, the presence of one base in several polyps, the disproportion between the size of the polyp and the length of the leg (large polyp and a short, wide leg). Finally, the question of malignancy of the polyp is decided after endoscopy and histological examination of the biopsy.

Early gastric cancer can be erosive and ulcerative, protruding (polypoid) and flatly infiltrating (Figures 57–61).

With erosive and ulcerative cancer, a moderately pronounced contrast spot is revealed on the relief, often not exceeding 1–2 cm in diameter; its shape is usually irregular, often stellate, the edges are corroded. In the process of motor activity of the stomach, a surface niche is determined, which changes its shape and size. When a deep peristaltic wave passes, it can disappear. When brought out to the contour, ulceration appears in the form of a thin stroke, the length of which is located along the lesser curvature. As a rule, the niche is surrounded by an inflammatory roller, which gives a light halo around the barium suspension depot with lubricated outer contours. Due to the development of sclerosis in the affected area, straightening and rigidity of the contour of the stomach wall, some straightening of the angle of the lesser curvature are noted. Convergence of folds of the mucous membrane often appears, local retraction of the opposite wall of the stomach can be observed.

A tumor protruding into the lumen of the stomach is characterized by proliferative-hyperplastic growth. There are the following types of protruding cancer: plaque, polypoid and in the form of a local thickening of the folds of the mucous membrane.

Plaque cancer manifests itself as a rounded, structureless filling defect on the relief of the gastric mucosa, less often as a central filling defect with clear, even boundaries.

Polypoid cancer resembles a sessile polyp. With tight filling of the stomach with barium suspension and dosed compression, a filling defect of an irregular oval or round shape (diameter of about 1 cm), in places with uneven and indistinct contours, is found.

The relief of the mucous membrane around the tumor with an area of 5–4 cm is changed and is represented by unevenly thickened folds resembling polypoid eminences.

It is very difficult to diagnose an initial cancer in the form of a local thickening of the folds of the gastric mucosa. With this form, in a limited area, often up to 3 cm in diameter, thickening of one or two folds of the mucous membrane is determined with a smooth gradual transition to the unchanged relief of neighboring areas, and these folds do not change their shape and size when the peristaltic wave passes.

Pathologically altered areas of the mucosal relief should be studied fibrogastroscopically followed by biopsy.

Exophytic stomach cancer is a bulging cancer that forms a polyposis or mushroom protrusion in the lumen of the stomach.

It is diagnosed by a filling defect of an irregularly rounded shape with indistinct contours. An accumulation (depot) of barium suspension in the filling defect is often observed, which indicates its ulceration. At the edges of the filling defect, the folds of the mucosa break off. Peristalsis of the stomach in the affected area is absent. When the tumor is localized in the cardiac region, the shape of the gas bubble changes, the fornix of the stomach deforms and thickens, asymmetry and unevenness of its contours appear. Characterized by the "symptom of an iceberg", due to the fact that the main part of the tumor is hidden in the barium mass, and its upper part appears as additional tissue, projected onto the gas bubble. The process very often involves the abdominal esophagus, which causes its deformation. The position and function of the gastroesophageal junction change. The esophagus deviates to the left, the contrast agent enters the stomach in a narrow broken stream and then spreads over the unevenly bumpy surface of the tumor. Throwing and splashing of a stream of barium suspension coming from the esophagus into the stomach, a gaping of the cardia can be observed.

Endophytic stomach cancer - cancer growing in the thickness of the stomach wall.

X-ray examination reveals a flat filling defect, usually of great length. The contours of the defect are sometimes rough, slightly wavy, in most cases straightened and visible only when the stomach is tightly filled with a barium suspension. The wall of the stomach at the level of the filling defect is rigid, does not peristalize. Often, shortening of the stomach due to infiltration of the lesser curvature and its deformation are detected.

With total damage to the walls of the stomach, microgastria develops. If the cancerous infiltration is limited to the body of the stomach, an hourglass-like deformation occurs. The folds of the mucous membrane are rigid, the relief is smoothed in places. With ulceration of the tumor, shallow depots of the contrast mass (flat niches) are determined, to which the folds of the mucous membrane can converge. Often, an angle forms at the border of tumor infiltration due to stretching of the stomach wall. When the tumor is localized in the pyloric zone, a filling defect is found that deforms the prepyloric stomach, an uneven pyloric lumen, and the disappearance of the folds of its mucous membrane.

Stomach cancer ulcerative (ulcerated) - cancer in which the symptom of ulceration predominates.

The longitudinal size of the niche is greater than its diameter and depth, the ulceration is located closer to the distal edge of the tumor and parallel to the long axis of the organ, it is irregular in shape with uneven bay-like outlines. The bottom of a cancerous ulcer is usually unevenly bumpy. The infiltrative shaft around the niche is large, asymmetric, elongated in the longitudinal direction, its edges are slightly raised, uneven, as if “blurred”. The final diagnosis is made by endoscopy with gastrobiopsy.

Stomach cancer is diffuse. It is localized more often in the antrum of the stomach.

It manifests itself as concentric, symmetrical narrowing and lengthening of the antrum. Irregular jagging (pitting) along one or both curvatures is characteristic. The part of the stomach wall not affected by the tumor hangs over the affected part of it in the form of a step. The relief of the mucous membrane at the onset of the disease is smoothed, later on, a "malignant relief" appears. The peristalsis of the walls in the initial stages of the disease is not disturbed; with the narrowing of the lumen of the organ, the aperistaltic zone is determined. In cases of subtotal and total lesions of the stomach, cancerous infiltration causes deformation and wrinkling of the affected walls, a decrease in the capacity of the stomach and the development of microgastria.

The sarcoma of the stomach is highly polymorphic and depends on the nature of the growth and the stage of the process. With a total lesion, the stomach has the shape of a funnel with a significantly narrowed, horizontally located outlet section. The contours of its walls are uneven. Large filling defects merging with each other are formed, between which there are wide rigid folds of the mucous membrane. Against the background of the affected gastric mucosa, single or multiple ulcerations can be detected - a depot of a contrast agent with undermined, uneven edges. The evacuation of barium suspension from the stomach is slowed down or occurs in a continuous stream.

For the nodular form of sarcoma, solitary or multiple rounded filling defects are characteristic. Peristalsis is usually not disturbed. With an infiltrative form of growth, the walls of the stomach are thickened, rigid. If the tumor grows predominantly perigastrically, a small flat contour defect, a moderate narrowing of the stomach lumen and a discrepancy between a large palpable tumor and mild X-ray symptoms are determined in the area of the stomach lesion.

Leiomyoma of the stomach. Like all benign stomach tumors, it is quite rare. It is localized more often on the back wall of the middle and lower third of the body of the stomach or in the antrum. Exosgastric growth is characteristic. Often calcified or ulcerated and bleeding.

Radiologically manifested by a filling defect of a round or oval shape with clear, even contours. A surface niche is often found in the center of the defect. The state of the mucosa in the area of the leiomyoma location depends on its size and direction of growth: the folds are arcuately pushed aside, spread apart, stretched or may be interrupted and not detected at all due to the sharp tension of the mucosa. Sometimes extragastric leiomyoma can pull off part of the stomach wall at its base, forming a depression in which barium suspension is retained, which creates a false picture of ulceration. In a third of cases, leiomyoma turns into leiomyosarcoma, but it is difficult to establish this radiographically.

Acquired pyloric stenosis (Fig. 62) is a narrowing of the pylorus, which makes it difficult to empty it. It may be caused by scarring of a stomach ulcer, tumor and other processes.

Compensated stenosis is characterized by increased segmentation peristalsis, alternating with a decrease in tone and moderate expansion of the stomach. Periodic fluctuations in tone are clearly expressed. The duration of the resting phases exceeds the duration of the periods of physical activity. Evacuation is slowed down.

Subcompensated stenosis is accompanied by vomiting, the tone of the stomach is reduced, the presence of fluid and food masses on an empty stomach is noted. Peristalsis is initially lively, but soon dies out, depletes, periods of short-term physical activity alternate with long rest pauses lasting up to 5 minutes. The contrast agent is retained in the stomach for a day or more.

With decompensated stenosis, the stomach is large, looks like a stretched sac with weak peristalsis, and in some cases - its absence. In the presence of peristalsis, rest pauses last up to 5-10 minutes. RKV in the stomach lingers for many days, settles in the form of a sickle or a bowl in the sinus of the stomach.

Cicatricial ulcerative stenosis is accompanied by a significant expansion of the stomach, the pylorus is asymmetrically narrowed, not elongated, the lesser curvature of the stomach is shortened, along the greater curvature there is a pocket-like protrusion. The relief of the gastric mucosa is preserved, thickening and tortuosity of the folds are often noted, sometimes a niche. The KDP bulb is deformed.

Menetrie's disease. It is characterized by a sharp hypertrophy of the gastric mucosa with the development of multiple adenomas and cysts in it, an increased protein content in gastric juice, which can lead to hypoalbuminemia, manifested by constant or intermittent edema.

Radiographically, a sharp increase in the caliber of the mucosal folds is found, reaching 2 cm in width and 2.5–3 cm in height, and they are very convoluted. Such massive, randomly and closely spaced folds outwardly resemble multiple polyp-like or large tuberous formations, especially along the large curvature in the sinus and body.

The process usually does not extend to the lesser curvature and antrum of the stomach. When a marginal filling defect is formed, the folds resemble a cancerous tumor, and the accumulation of barium between the folds is imaginary ulceration. A feature of the relief is its variability (folds are lengthened and rearranged with dosed compression).

Thickened folds of the stomach

Thickening of the folds of the gastric mucosa can be observed in both benign and malignant diseases. If gastroscopy with biopsy cannot determine the nature of these changes, an EUS is necessary. While gastritis, foveolar and glandular hyperplasia can be easily verified with mucosal biopsy, diagnosis in diffuse gastric cancer (in which the mucous membrane may not be altered), lymphoma, or gastric varicose veins in some cases is difficult.

If a thickening of the fourth layer is determined and deep biopsies (including scraping) performed during gastroscopy are not informative, exploratory surgery is recommended to confirm the diagnosis of gastric cancer. There is a report on the data of EUS in case of thickening of the folds of the gastric mucosa, caused by various reasons. In patients with Menetrie's disease (adenopapillomatosis, giant hypertrophic gastritis), only the second layer was thickened; in patients with anisacidosis (zoonotic helminthiasis), only the third layer thickened. In most cases of scirrhoid cancer, thickening of the third and fourth layers was revealed.

In healthy people, with an accidentally detected thickening of the folds of the gastric mucosa, an increase in the thickness of the second and third layers was determined; on the contrary, thickening of the fourth layer was observed only in malignant lesions. In patients with foveolar hyperplasia, two inner layers are thickened. Varicose veins of the stomach are manifested by the presence of hypoechoic vessels in the submucosa and perigastric region. Doppler ultrasound can be used to confirm the vascular nature of the changes, but this is usually not necessary.

The value of stomach ultrasound

EUS can help assess lesions of the stomach wall and perigastric region. In many medical institutions, EUS is used to determine the stage of gastric malignant neoplasms and to develop therapeutic tactics. It is the most reliable method for staging a tumor and diagnosing submucosal formations. EUS-guided fine-needle aspiration biopsy allows for an accurate diagnosis and determination of the stage of the disease (including involvement of the lymph nodes).

It has been shown that EUS can influence the choice of treatment tactics in more than two thirds of patients. In more than half of the cases, these data allow for less costly, hazardous and / or invasive treatments.

Endoscopic diagnosis of gastric ulcer, gastritis, tumor

Chronic gastritis is a clinical and anatomical concept, characterized by certain pathomorphological changes in the gastric mucosa - a nonspecific inflammatory process.

A visual assessment of the state of the gastric mucosa in conjunction with targeted biopsy and the possibility of using various dyes makes it possible to accurately differentiate the forms of gastritis, determine their prevalence, and the phase of the disease.

The main endoscopic signs on which the diagnosis is based.

The nature of the folds. The folds of the stomach lining are usually easily expanded with air. Only with pronounced edema and infiltration of the mucous membrane do they have a thickened appearance at the beginning of insufflation.

The color of the gastric mucosa. Normally, the stomach lining is pale or pale pink; with inflammation, it acquires a red color of different shades and intensity. Sometimes, more often in the antrum, hyperemia appears on a pale background, resembling a scarlet rash in appearance.

Type of mucous membrane. If areas of the discolored are interspersed with normal, the mucous membrane acquires a variegated, mosaic appearance. On the gastric mucosa, semicircular formations with a diameter of 0.2 to 0.3 cm protruding above the surface are often found. They are single or completely cover the surface of the mucous membrane. The latter at the same time looks grainy. "Granularity" is more common in the antrum and in the body of the stomach on the greater curvature. The inflamed mucous membrane gives the impression of pasty, dull, loose, easily vulnerable.

Vascular drawing. It is especially clearly visible with the usual inflation of the stomach with air against the background of a pale mucous membrane with atrophic gastritis.

Mucus overlays indicate mucosal inflammation. They are of a different nature: foamy, transparent, white or colored with bile, cloudy, sometimes fibrinoid overlays, difficult to wash off with water.

Reflux During the study, you can observe the reflux of gastric contents into the esophagus or duodenal contents (bile) into the duodenal bulb or stomach - gastroesophageal, duodenobulbar and duodenogastric reflux.

Atrophic gastritis is characterized by thinning of the mucous membrane, visual enhancement of the vascular pattern, and a decrease in the size of the folds. The mucous membrane acquires a pale grayish color. The severity of the endoscopic picture depends on the degree of atrophy and the extent of the process on the gastric mucosa.

With moderate atrophy, wider areas of slightly thinned mucous membrane alternate with small fields of pale gray depressions of various configurations. There is a so-called "false" hyperemia (against the background of pale areas of atrophy, the normal mucous membrane looks hyperemic).

With pronounced atrophy, the mucous membrane is sharply thinned, with translucent vessels, gray, in places with a cyanotic tinge, easily vulnerable, folds almost completely disappear. Histological examination of the material usually reveals intestinal metaplasia.

Congestive gastropathy (hypertrophic gastritis). The most characteristic sign of congestive gastropathy is an increase in the volume of the mucous membrane. In essence, with this type of gastritis, it would be more correct to talk about a hyperplastic process. However, quite often there is a discrepancy between micro- and macroscopic data in this disease.

The increased volume of the mucous membrane leads to an increase in the height and thickness of the folds. They take on a crimped appearance. The mucous membrane is moderately edematous, hyperemic. Between the enlarged folds, accumulations of mucus are formed, which, against the background of pronounced hyperemia of the mucous membrane, can be mistaken for an ulcerative crater. In some cases, growths of various shapes and sizes appear on the thickened folds.

A distinctive feature of this type of gastropathy is the presence of diffuse hyperemia of the mucous membrane, which is a differential diagnostic criterion for distinguishing it from gastric polyposis. With polyposis, hyperemia is absent or is determined only at the tops of the polyps. For the sake of fairness, it should be noted that the final diagnosis is possible only with a histological study of the biopsy material.

Menetrier's disease (P. Menetrier) is a rare disease characterized by giant foveolar hypertrophy of the folds of the gastric mucosa.

The folds increase in volume so much that their tops touch each other, completely closing the lumen of the stomach.

In the lumen and between the folds, a large amount of a viscous secretion of a dull white color is found. Films of fibrin often appear on the folds. Morphological examination reveals pronounced hyperplasia of the superficial epithelium, restructuring of the glandular apparatus with the appearance of a large number of mucus-secreting cells and signs of diffuse inflammation.

The etiological factors and the mechanism of development of Menetrie's disease have not been studied enough. The reasons suggest: chronic intoxication (alcohol, lead), nutritional errors, hypovitaminosis, infectious diseases (viral hepatitis, dysentery, typhoid fever, metabolic disorders, neurogenic and hereditary factors. to increase the permeability of the gastric mucosa.It is possible that the disease is a consequence of developmental abnormalities.Menetrie's disease is a precancerous condition.

Peptic ulcer disease. In terms of prevalence, it ranks second among all diseases of the stomach. Peptic ulcer (peptic ulcer) of the stomach and duodenum is a chronic recurrent disease that occurs with alternating periods of exacerbation and remission, which is based on the inflammatory response of the body with the formation of local damage (ulcers) of the mucous membrane of the upper gastrointestinal tract, as a response to violation endogenous balance of local "protective" and "aggressive" factors.

From the point of view of nosological isolation distinguish between gastric ulcer and duodenal ulcer, associated and not associated with Helicobacterpylori, drug and symptomatic gastroduodenal ulcers.

According to statistics, ulcers often affect the lesser curvature (45-50%), pyloric and prepyloric sections (38-45%). Much less often (8-10%) - the upper sections, the anterior and posterior walls (3-5%), very rarely the bottom and greater curvature (0.1-0.2%).

The most common classification is Johnson (1965), according to which there are:

Type I ulcers - ulcers of the lesser curvature of the stomach (above 3 cm from the pylorus).

Type II ulcers - combined stomach and duodenal ulcers.

Type III ulcers - ulcers of the prepyloric stomach (no further than 3 cm from the pylorus) and the pyloric canal.

Sometimes type IV is also distinguished - duodenal ulcers.

According to the number of ulcerative lesions, single (most often) and multiple ulcers are distinguished. There are ulcers of small (up to 0.5 cm in diameter), medium (0.6-1.9 cm in diameter), large (2.0-3.0 cm in diameter) sizes, as well as giant (over 3.0 cm in diameter).

The main complications of peptic ulcer disease: bleeding, perforation, penetration, malignancy, cicatricial ulcerative stenosis.

In the acute stage, a chronic stomach ulcer has a rounded or oval shape. The edge facing the cardia protrudes above the bottom of the ulcer, as if undermined, and the edge facing the gatekeeper, most often more smoothed, shallow. The periulcerous shaft increases due to edema, as a result of which the ulcer crater visually deepens. The bottom of the defect is covered with yellow-gray fibrin. The mucous membrane around the ulcer is hyperemic, edematous, or may not be changed.

The endoscopic picture of a healing ulcer is characterized by a decrease in hyperemia of the surrounding mucous membrane and peripheral inflammation. The inflammatory shaft around the ulcer smoothes out, decreases, the ulcer itself becomes less deep, the bottom of the ulcer is cleared and covered with granulations. With repeated gastroscopy at the site of the former ulcer, a more hyperemic area of the mucous membrane is revealed - the stage of the "red scar". Subsequently, retraction of the wall is formed and a connective tissue scar of various shapes is formed - the stage of the "white scar".

Histological examination of biopsy material taken from the edges of the ulcer defect is mandatory.

Submucous tumors of the stomach account for 1/3 of all tumors of the organ. They grow under mucous tumors from non-epithelial (nervous, muscle, adipose, connective) tissue, are often mixed and can be benign and malignant. Macroscopic diagnosis of the type of submucosal tumor is difficult. The rate of correct diagnosis based on visual data is%.

The endoscopic picture of submucosal tumors is determined by the nature of their growth, location in the wall of the organ, size, the presence of complications, the amount of air injected and the degree of stretching of the stomach walls. The growth of tumors can be exo-, endophytic and intramural.

Based on only visual data, it is impossible to determine either the morphological structure or the nature of the tumor. A biopsy is not very informative, since it is impossible to take material from deeply located tissues. In this case, it is recommended to make a biopsy from the same area, gradually going deeper into the tissue. However, this is fraught with the development of bleeding.

Polyps of the stomach. It is customary to call a polyp any formation of not only epithelial, but also connective tissue origin, which will stand in the lumen of the organ. Polyps are detected in 2-3% of patients during screening examinations.

Based on the results of morphological studies of removed neoplasms, the following types of stomach polyps are distinguished:

Hyperplastic (focal hyperplasia);

Border protruding lesion (proliferation of glandular epithelium with epithelial atypia);

Early cancer (type I and II a).

It is believed that hyperplastic and adenomatous polyps do not undergo malignant transformation. The third and fourth types of polyps are borderline types with the transition to the fifth, which are early forms of cancer types I and IIa.

Endoscopy evaluates the endoscopic signs of polyps and the nature of changes in the gastric mucosa, which are the background on which the polyp develops. Endoscopic description includes: the number of neoplasms, their localization, shape, size, presence of a leg, surface, color, consistency, relation to surrounding tissues, inflammatory changes.

Based on the assessment of these signs, it is believed that the criterion for the benignity of polyps is their size: less than 15 mm for flat polyps, 10 mm for polyps with a short stalk and 20 mm for polyps with a long stalk. However, the diagnostic value of these indicators is relative. Visual signs cannot serve as criteria for the benign quality of a neoplasm. The final diagnosis can be made only after a histological examination of the entire removed neoplasm, together with its base.

Stomach cancer OMED classification of gastric cancer:

Type 0 - early cancer;

I. type - polypoid;

Type II - ulcerative (malignant ulceration);

Type III - mushroom-like with ulceration;

IV type - diffuse infiltrative cancer;

Type V is a common (unclassified) cancer.

Early stomach cancer. The most significant problem of endoscopic examination is the detection of early gastric cancer. Visual diagnosis of early forms of gastric cancer and their differential diagnosis with benign polyps and ulcers is very difficult due to the absence of typical endoscopic signs.

The solution to the issue of high-quality diagnostics is facilitated by the introduction into clinical practice of additional research methods - biopsy, chromogastroscopy, spectroscopy, etc.

Polypoid cancer (3-18%) is an exophytic growing tumor with clear boundaries. Wide base, round or irregular shape. The surface of the tumor can be smooth, bumpy or nodular, with ulcerations of various shapes and sizes, covered with a dirty gray necrotic plaque. The tissue of the tumor is grayish-yellow or purple-red in color, ranging in size from 3 to 8 cm. Tumors are more often single, less often - multiple and separated from each other by sections of unaffected mucous membrane. The base of the tumor is clearly contoured and delimited from the surrounding tissues.

Ulcer-like cancer - malignant ulceration (10-45%) - looks like a large deep ulcer with a diameter of 2-4 cm, delimited from the surrounding mucous membrane. The edges are uneven, undermined and look like a thickened shaft, towering above the surface of the mucous membrane at different levels, its surface is uneven, bumpy, knotty. In some areas, the bottom seems to float over the edge and the defect takes on the shape of a "saucer". The bottom is uneven, covered with a bloom of dirty gray or dark brown color. Often, blood clots and thrombosed vessels can be seen at the bottom of the ulcer. There is an increased contact bleeding of the edges of the ulcer, the surrounding mucous membrane is atrophic.

Fungus cancer with ulceration (45-60%), in fact, is the next stage in the development of ulcerative cancer (non-infiltrative ulcer). This type of tumor is presented in the form of an ulcer located on the background of cancerous infiltration of the mucous membrane. An infiltrative ulcer has not pronounced edges, which are absent in several places. The tuberous bottom passes directly into the surrounding mucous membrane. Its relief is "frozen" due to cancerous infiltration. The folds are rigid, wide, low, cannot be straightened by air, peristaltic waves are not traced. There is no "contrast" between the edges of the ulcer and the surrounding mucous membrane. Fungus cancer with ulceration leads to gross deformation of the organ.

Diffuse infiltrative cancer (10-30%) with submucous growth is rather difficult to diagnose. Diagnosis is based on indirect signs: the rigidity of the organ wall at the site of the lesion, the smoothness of the relief and the pale coloration of the mucous membrane.

As the mucous membrane is involved in the process, a typical endoscopic picture of a "malignant" relief develops: the affected area swells somewhat, the folds are motionless, "frozen", are poorly expanded by air, there is a decrease in the elasticity of the organ wall and narrowing of its cavity (type of "leather bottle"), reduced or there is no peristalsis, a "lifeless" mucous membrane, the color of which is dominated by gray tones.

A rather pathognomonic symptom can be observed - the distal edge of the infiltration rises sharply above the unaffected mucous membrane - the “shelf effect”. Intramucosal hemorrhages, erosion and even ulcers can be observed, which is associated with the addition of infection and the development of inflammatory infiltration. In these cases, infiltrative cancer is visually difficult to differentiate from superficial gastritis or chronic ulcers. The resulting acute ulceration when inflammation subsides can heal. This should always be borne in mind and biopsied for all acute ulcerations.

The concept of stomach polyps includes various formations of a non-epithelial nature that develops on the mucous membrane, as a result of inflammatory, tumor, regenerative changes. Based on morphological studies, these neoplasms are divided into:

hyperplastic;
adenomatous (hyperplasiogenic);
adenomas;
proliferation of the glandular epithelium, the so-called borderline lesion;
early cancer.

The greatest probability of the degeneration of the initially benign proliferation of mucosal cells into a malignant tumor (cancer) exists for the glandular polyps of the cardiac part of the stomach. The next most frequent overgrowth is the antrum and pylorus.

Among the various theories explaining the causes of the development of adenocarcinoma of the stomach, as otherwise called glandular cancer, the most common causes of an inflammatory nature, a violation of the normal process of recovery of mucosal cells (hyperplasia) and the theory of embryonic dystopia. Given the high degree of probability of malignancy, regardless of the type of gastric polyps, only surgical intervention by polypectomy or abdominal surgery is recommended. When determining the indicators for endoscopic polypectomy, the most popular and widespread classification is the Yamal, which, according to the form of neoplasms of the mucous membrane, divides them into four types.

Types of stomach polyps:

Type 1. Small flat plaque eminences.
Type 2. Hemispherical formations with a wide base without a leg.
Type 3. Polyp is round or oval in shape on such a short stalk that it seems to be sitting on a mucous membrane.
Type 4. Differs in a well-formed long leg, which can be several centimeters.

Type 1 polyp in the stomach

This type is determined at the very beginning of the disease during an X-ray examination for the treatment of another disease. They are single and multiple in nature, but due to their small size, as a rule, there are no symptoms. At the same time, if, according to morphological characteristics, the formation belongs to the adenomatous type, then there is always a danger of their development into adenocarcinomas (cancer). Concomitant diseases with a type 1 polyp in the stomach are mainly chronic atrophic gastritis and infection of the stomach with Helicobacter pylori microorganisms.

Against this background, neuroendocrine tumors are formed. In this case, first of all, the disease is treated, against the background of which the polyp of the first type develops. With early diagnosis, drug therapy is effective, in combination with a strict diet and folk remedies. Maintaining a healthy lifestyle, eating habits and avoiding annoying factors is critical. In this case, the patient must be under constant medical supervision.

To ensure accurate detection of the smallest benign tumors, as well as to conduct a study of biopsy material in order to exclude the development of cancer, gastroscopy is the most reliable method. X-ray studies with polyps less than 5 mm in size do not give one hundred percent guarantee of determining their malignancy. Removal of small neoplasms is carried out using a point coagulator, but a biopsy examination is mandatory.

Type 2 stomach polyp

Type 2 polyps can be of a wide variety of sizes and different histological forms. Microscopic analysis of these neoplasms shows that they consist of an atrophied or hypertrophied mucous membrane with an overgrown integumentary epithelium and glands connected by the stroma. They are divided into adenomatous, angiomatous, granulomatous, which are determined depending on the predominance of glands, blood vessels and granulation tissue in tumors.

Among all types of polyps, a hemispherical formation without a leg is the least common. The main symptoms of this disease are dull aching pain in the epigastric region associated with eating foods rich in coarse fiber or including spicy, highly salty, smoked or pickled foods in the diet. In the course of the further development of the disease, the connection between pain and food intake disappears, but when passing near the exit section and increasing the size of the build-up, intestinal obstruction or symptoms of an "acute" abdomen occur.

Almost half of the patients have unpleasant phenomena in the form of belching, nausea, heartburn, and bouts of vomiting. Usually these manifestations are associated with concomitant gastritis. The possibility of slight injury to the neoplasm when passing through rough food causes latent bleeding, revealed by the study of feces. With fluoroscopy, the main symptom of this type of disease is a "filling defect" of a hemispherical shape with clear even contours against the background, which has remained unchanged, of the mucous membrane.

With adenomatous papillary neoplasm, due to the penetration of a specific suspension between the villi, the contours become blurry, with, as it were, pitted edges. When the formation degenerates into a malignant tumor, the contours become uneven with jags. Compared to the environment, polyps are brighter in color, and when they are expressed, the color changes in the range from light pink to dark brown, and they become covered with spots.

A more accurate picture can be established by combining the X-ray method with gastroscopy. If, at the same time, the size of the tumor exceeds 2 centimeters and there is no boundary of the transition of the formation into the gastric mucosa, the surface is uneven and bumpy, whitish in color, then this indicates the possibility of polypoid cancer. Accurate data can be obtained by examining a biopsy sample.

The danger of using electroexcision with a diathermic loop to remove a neoplasm that does not have a leg is the possibility of bleeding at the site of removal and perforation of the stomach wall. Therefore, the safest and most reliable treatment for this disease is surgical polypectomy.

Type 4 polyp

Like other types of polyps, this type can have different histological and morphological forms, it can be singular or plural. From the point of view of the risk of degeneration, a neoplasm on a long stem is less dangerous than a wide base or a short leg of a large diameter. The presence of a leg is determined when the "filling defect" is displaced. The possibility of prolapse of polyps on a long leg into the duodenum and pinching it in the gatekeeper, causes sharp, cramping pains, vomiting, and the urge to nausea.

If the leg is thin, then the removal of a small protrusion on the mucous membrane is performed on an outpatient basis during gastroscopy. Endoscopic polypectomy is widely used in the treatment of type 4 polyps. The control examination is carried out 10-12 days after the operation. In the future, it is necessary to conduct examinations no earlier than once a year, with the obligatory observance of the recommendations for proper nutrition and a healthy lifestyle.

Menetrie's disease, or giant-fold gastritis, is a disease associated with inflammation of the stomach, a characteristic feature of which is an increase in the cells of the mucous membrane of this organ. The first researcher of her clinical picture in 1888 was the French physician P. E. Menetner, after whom she was named.

Other names for this disease are chronic hypertrophied polyadenomatous gastritis, exudative gastropathy, giant hypertrophic gastritis, excess gastric mucosa, adenopapillomatosis, tumor-like gastritis.

Anatomy of the stomach with hypertrophic gastritis

With this disease, the mucous membrane of the stomach thickens, its folds reach a height of more than 3 centimeters. Localization of such manifestations is most often in the area of the greater curvature of the stomach.

The hypertrophy of the folds is rarely limited; in many cases, the changes affect most of the mucous membrane.

The main and parietal cells become smaller, and the mucus-forming cells increase mucus production and grow in size themselves. As a result, the stomach glands increase in size and turn into cysts. Multiple cysts lead to polyadenomatosis.

The folds of the mucous membrane undergo a focal inflammatory process. The stomach lining becomes permeable to gastric juice and protein. When the inflammatory process spreads to the vessels of the mucous membrane, gastric bleeding appears.

Reasons for the appearance

Insufficiently studied pathology does not make it possible to establish the exact causes of the onset of Menetrie's disease. Supposed causes of hypertrophic gastritis:

Metabolic disorders.
Intoxication with alcohol, nicotine and industrial hazards (lead).
Lack of vitamins in the diet.
Consequences of past infections (hepatitis, dysentery, typhoid fever).
Heredity factors.
Hypersensitivity to food allergens.
Anomalies of development at the stage of the embryo.
The consequences of the inflammatory process of the gastric mucosa.
The tumor is benign.

For more information on gastritis with mucosal hypertrophy, see the video:

Clinic of the disease

The development of the disease is slow, periods of exacerbation alternate with periods of long-term remission.

In some patients, the clinical manifestations of this disease subsides, passing to the clinical manifestations of atrophic gastritis, becomes a precancerous condition. Symptoms of giant fold gastritis:

Pain in the epigastric region after a meal is of varying duration and intensity.
Feeling of heaviness and fullness in the stomach.
Diarrhea, vomiting.
Loss of appetite and a sharp weight loss associated with this symptom (by 10-20 kg), turning into anorexia in advanced cases.
Peripheral edema due to protein loss.
Insufficient stomach bleeding, anemia.

Laboratory tests of the blood of a patient with Menetrie's disease may show a slight decrease in neutrophilic leukocytes, hemoglobin and red blood cells. It is possible that the disease will be asymptomatic.

Diagnosis of Menetrie's disease and differentiation from other diseases

If symptoms of the disease appear, consultation with a gastroenterologist is necessary. This rare type of gastritis requires accurate diagnosis and differentiation from other diseases. Types of diagnostic examinations for Menetrie's disease:

X-ray.
Endoscopic examination.
Mucosal biopsy.

X-ray examination is able to reveal changes in the mucous membrane. The manifestations of the limited form of Menetrie's disease look in this study as irregularly shaped pillow-like formations. These sinuous, thick folds protrude into the lumen of the stomach and are well diagnosed.

A common form of the disease manifests itself in a similar way in the body of the stomach, on its fornix and in the sinus. Normal folds of the mucous membrane are detected only in the antrum of this organ. Radiography states that the walls of the stomach have not lost their elasticity and the ability to contract, their peristalsis is perfectly recorded.

Endoscopic examination of the stomach with giant-fold gastritis plays a leading role in the diagnosis of the disease. The folds in the body of the stomach look like a cobblestone pavement, or are associated with cerebral convolutions. They may have a large number of erosions on their surface, look pale and swollen.

When the organ is dosed with air, these folds are not straightened. During endoscopic examination, targeted aspiration biopsy of large areas of mucosa is performed. This study can confirm or deny the presence of cysts and enlarged mucus glands.

To complete the picture, as well as to differentiate Menetrie's disease from a malignant tumor of the stomach, endoscopic examination is repeated a month later. It is possible to conduct a trial laparatoskomy to completely exclude a malignant process in the stomach. In addition to the oncological process, giant-fold gastritis is differentiated from the following diseases:

Hypertrophic gastritis.
Tuberculous lesion of the stomach.
Polyps of the stomach (Peitz-Touraine-Jeghers syndrome).
Common familial polyposis (Cronckheith syndrome - Canada)
Syphilitic affection of the stomach.
Benign tumors of the stomach.

Additionally, you can conduct a pH-metry in order to measure the acidity of gastric juice. With Menetrie's disease, this indicator is usually reduced.

Menetrie's disease in children

This disease is extremely rare in children. Isolated cases of giant-fold gastritis in the pediatric population made it possible to identify differences in the manifestations of this pathology from the same symptoms in adults.

In children, Menetrie's disease does not turn into a chronic recurrent form, it tends to self-limit its course and development, almost never gives complications. Symptoms of the disease in children:

Sudden attacks of nausea.
Pain in the epigastric region.
Lack of appetite.
Hypoproteinemia.
Peripheral edema of the extremities, ascites.
Hypoalbuminemia.
Indicators of a general blood test - eosinophilia, normocytic anemia.
An x-ray shows a thickening of the folds of the mucous membrane in the body and at the bottom of this organ.
The results of endoscopic ultrasound scanning, gastroscopy, endoscopy - hypertrophy of the folds of the mucous membrane.
Histological examination - mucosal hypertrophy, glandular atrophy, intranuclear cytomegalovirus inclusions.
Sowing stomach tissues - cytomegalovirus (in most cases of the disease in children).
Giant-fold gastritis in children responds very well to therapeutic treatment.

Treatment of the disease

Despite the fact that no more than 300 patients have been described in the medical literature to date, gastroenterology has accumulated sufficient experience to relieve the symptoms of the disease.

Patients with Menetrie's disease must register for dispensary and repeatedly undergo apparatus examination.

Diet for this pathology is an indispensable condition for effective treatment. It should be gentle, not aggravate the condition of the damaged gastric mucosa. Spices, spicy, fatty, fried food with this disease for the patient is under the strictest prohibition.

Since protein loss through the stomach lining is one of the symptoms of this disease, a large amount of easily digestible proteins is included in the menu. Regularity of food intake and temperature is an important part of the diet. Food should only be warm, not irritate the mucous membrane damaged by ulcers.

Food components should not be too coarse, some of the dishes can be taken in pureed form. Mucous soups and cereals enveloping the mucous membrane are useful. Conservative treatment in addition to diet includes the following drugs:

Astringents and coating agents.
Pain medications.
Antispasmodics.
Digestive enzymes.
Vitamins.
Fortifying agents.
Substitutes that increase the acidity of gastric juice (Panzinorm, Plantaglucid, natural gastric juice, Polysim, Abomin, Mexase, 1% solution of hydrochloric acid with pepsin).
Anticholinergic drugs.

If the diagnosis has shown the presence of ulcers of the mucous membrane, treatment is carried out similar to the same treatment for stomach ulcers. In case of an unfavorable prognosis of the development of the disease and persistent manifestation of complications (edema of the extremities, gastric bleeding, pain in the epigastrium), surgical intervention is performed - gastrectomy. Possible complications of Menetrie's disease:

Malignant degeneration of the mucous membrane (malignancy).
Sepsis.
Thromboembolism.
Gastric bleeding.
Anemia.
Chronic pain syndrome.

Since the causes of the disease have not been identified with complete certainty, it is impossible to take adequate preventive measures. It is advisable to avoid bad habits, maintain the body's immune defenses at a high level, and follow a rational diet.

For patients with this type of gastritis, the optimal prevention of relapse will be a timely visit to the doctor, following his recommendations, and regular diagnostic procedures.

Menetrie's disease is a rare inflammatory disease of the stomach, when its mucous membrane is overdeveloped, hypertrophied into giant folds. The causes of this pathology are not well understood, diagnostic methods allow determining an accurate diagnosis and prescribing adequate treatment.

In children, Menetrie's disease is extremely rare, proceeds without complications, and responds well to treatment. In adults, complicated forms of the disease that do not respond to drug therapy lead to surgery.

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