Description:

A 47 yrs male patient was considered for OGD scopy sos intervention in view of recent h/o malena/ haematochezia. Patient has h/o similar episode with detected ulcer on endoscopy done elsewhere a few years ago. Patient also complains of wt loss.

• OGD scopy  revealed irregular nodular mucosal changes with abnormal appearing anterior wall of stomach body with a large ulcer with actively bleeding artery in the base.
• Proximal duodenum appeared normal
• The actively bleeding ulcer was treated with heater probe coagulation.
• Complete haemostasis was ensured. To add we injected diluted saline adrenaline around the ulcer to create tamponade.
• Biopsies were taken from the ulcer edges for histology.
• Previously treated ulcer in the stomach appeared healing and medical treatment seems to be reducing the gastric inflammation.
• Diagnosed bleeding gastric ulcer that was treated few days back and therefore this relook endoscopy sos EUS.
• Minimal hypoechoic thickening (9.0mm) was noted in the ulcer site, but it appeared more like an inflammatory rather than neoplastic.
• One hypoechioc 1.0 cm node was seen in the celiac axis region.
• No obvious mass lesion seen in the stomach otherwise.
• Final HPE & IHC of the biopsy showed MALT Lymphoma secondary to H.Pylori
• Patient was then treated with medical treatment for H.pylori eradication

TAKE HOME MESSAGE

This case exemplifies that High Definition Endoscopy with NBI is a very important feature to examine the mucosal changes and the pitt pattern to ascertain which areas to biopsy. Here we found abnormal looking gastric mucosa around actively bleeding ulcer. This lesions turned out to be MALT Lymphoma on histopathological examination and was verified with IHC studies too. The actively bleeding ulcer was managed at the same time. Endoscopic Ultrasound allowed us to evaluate the gastric wall thickness and more detailed examination and hence this particular case is unique in the sense that it required active therapeutic endoscopic intervention as well as high quality imaging to reach to a definitive diagnosis. We are indeed fortunate to have some of the most advanced Endoscopic Imaging equipments and expertise at WGI.

Image:

1. A large ulcer with actively bleeding artery in the base

2. The actively bleeding ulcer was treated with heater probe coagulation.

3. . Complete haemostasis was ensured. To add we injected diluted saline adrenaline around the ulcer to create tamponade.

4. Biopsies were taken from the ulcer edges for histology.

 

 

5. Proximal duodenum appeared normal

6. Previously treated ulcer in the stomach appeared healing on NBI view

7. Minimal hypoechoic thickening (9.0mm) was noted in the ulcer site

8. One hypoechioc 1.0 cm node was seen in the celiac axis region.