Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection

eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkM2NhNDY1NDUyZjc2MGEyN2ZmZTJlNTdmMTE3NjBhZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzAzNDQyOTA5fQ.h9v4TLXtTwT6GGX9MJj1foQKbz6ynjmDU6Q8WmHjXOiUGXT0RMLBgHDVug8iNu1Q2zdVAzupy5qhqRMMJ2R0mRggXQFBoC6sOlWwbZj4EAmbJ_DSeETbTSiqnMrPa1WlpRiEOVo6AZh5Snd0w2B1YxaEEiAmWdcvo8-l9zfNdiuWJ-5DjHGvHfP_dMokczwcutBM13pp02SSS1giESJHzRYgdk2jtCuNfZWZDDZNTsrE1d-74sqLNGUHMyIVn1gNSWIqPIsWBWoILRH53fIsxKAudEg6oXUtinsGPpJOvdbq3aeH_vhE7PuE_0bnvgrS5DwNAuouvCjZbAtIsXwWEg(mp4, (97.33 MB) Download video Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection: A 75-year-old woman with a several-week history of intermittent postprandial nausea and vomiting presented to the emergency room after experiencing syncope, following several hours of persistent abdominal pain, nausea, and vomiting. A contrast-enhanced CT scan of the abdomen and pelvis was arranged. Axial images show gastrogastric intussusception with the intussusceptum, indicated by the dashed lines, telescoping into the intussuscipiens indicated by the arrowheads. There is a lobulated mass indicated by the asterisk, serving as the lead point for the intussusception, and there is also a small volume of fluid indicated by the arrow, which delineates the mass from the duodenum. In the coronal images, we can again see a long-segment intussusception indicated by the dashed line with a lobulated mass indicated by the asterisk serving as the lead point and extending into the proximal duodenum. Then the lobulated mass occupying and expanding the duodenal lumen can be seen, indicated by the asterisk. Upon entry into the stomach through endoscopy, the gastrogastric intussusception can be seen. The lobulated mass serving as the lead point can be seen being pulled distally. With air insufflation, the intussusception spontaneously resolved. With continued insufflation, within a few minutes, the native confirmation of the polyp was established. It was located in the proximal body along the greater curve with a lobulated appearance with a Paris 1sp morphology. In addition, there was panatrophy in the background mucosa, which was consistent with autoimmune atrophic gastritis that was subsequently confirmed on histopathology and positive anti-parietal cell antibiotics. An EUS was performed and did not show any evidence of T2 disease. Doppler showed large central feeding vessel. A plan was made for endoscopic submucosal dissection (ESD). The strategy for the ESD was an initial circumferential incision and trimming with subsequent application of multipoint traction. After a circumferential incision, a rich vascular supply is seen. After completion of the incision and trimming, the snare was advanced over the scope and the clip advanced through the instrument channel. Multiple clips were then used to secure the snare to the distal end of the lesion. With traction applied, access to the submucosa became much easier and the ESD proceeded easily. For the final remnant of submucosa, it was more easily dissected in a forward view. Chess is one of the merits of multipoint traction in that traction can be applied both proximally and distally to the lesion. The lesion was resected en bloc. The specimen was retrieved using the attached snare, but unfortunately, some of the friable head was fragmented because of its large size, yet the base remained intact. Final pathology demonstrated PGD+HGD with clear margins vertically and laterally along the base. This case of gastrogastric intussusception, causing gastric outlet obstruction and acute pancreatitis secondary to a large pyloric gland adenoma, highlights several rare clinical entities. First, gastrogastric intussusception in adults is an exceptionally rare phenomenon, with only a few documented cases reported in the literature. Second, in the case of large gastric neoplasms causing intussusception, rarely the neoplasm may extend down into the duodenum and obstruct the ampulla of Vater causing acute pancreatitis. Furthermore, pyloric gland adenomas are rare gastric neoplasms that tend to be polypoid in morphology and are associated with autoimmune gastritis, predominantly occurring in female patients, as in this case. Lastly, the traditional management for lesions causing gastroduodenal intussusception is surgical because of the risk of malignancy. However, in this case, the patient underwent successful curative and therapeutic endoscopic resection with ESD. A 75-year-old woman presented to the emergency department with syncope, nausea, vomiting, and abdominal pain. She had been experiencing intermittent postprandial nausea and vomiting for several weeks. A CT scan of the abdomen and pelvis revealed gastric outlet obstruction secondary to gastrogastric intussusception from a 5-cm mass extending into the proximal duodenum (Fig. 1; Video 1, available online at www.videogie.org). In addition, the patient had pancreatitis, which was attributed to the intussuscepted gastric mass causing obstruction of the ampulla. During upper endoscopy, the mass was observed prolapsing into the duodenum (Fig. 2A). However, with insufflation, the intussusception spontaneously resolved (Fig. 2B). The lesion seen along the greater curve of the proximal body had a Paris 1sp morphology. The background body mucosa displayed panatrophy, indicative of autoimmune atrophic gastritis. Radial EUS demonstrated a second-layer lesion without evidence of muscularis propria involvement. There were 3 main reasons for choosing endoscopic submucosal dissection (ESD) over endoscopic mucosal resection (EMR) for management:1.Oncologic: Gastric adenomatous lesions greater than 2 cm have significant risk of carcinoma. This lesion was 5 to 6 cm.2.Hemostatic: With ESD, much more precise cutting is possible, along with the ability to perform hemostasis on vessels. In contrast, EMR involves transecting a large area rapidly without much precision.3.Perforation risk: Considering that this lesion caused intussusception and was quite bulky, it was believed that EMR would be less safe. In some cases, areas thought to be pedunculated when snared can lead to significant perforations in EMR. However, with ESD’s higher precision, if an incorrect plane is noted and a small perforation occurs, it can be easily closed. The patient underwent ESD using a 2-mm FlushKnife BTs (Fujifilm, Tokyo, Japan) and multipoint traction (Fig. 2C).1Shimamura Y. Inoue H. Ikeda H. et al.Multipoint traction technique in endoscopic submucosal dissection.VideoGIE. 2018; 3: 207-208Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The ERBE VIO 3 (Tübingen, Germany) was used with preciseSECT effect 4.0 and ENDO CUTI effect 2, duration 2, interval 2. The lesion was successfully removed en bloc; however, because of its substantial size, it fragmented during the process of being pulled across the esophagogastric junction. Fortunately, the fragmentation occurred at the friable head of the lesion rather than at the base, thus not impairing margin assessment. The patient was discharged in 48 hours without issue. The final pathology was pyloric gland adenoma with high-grade dysplasia that was completely excised (Fig. 2D). This case of gastrogastric intussusception, causing gastric outlet obstruction and acute pancreatitis secondary to a large pyloric gland adenoma, highlights several rare clinical entities. First, gastrogastric intussusception in adults is an exceptionally rare phenomenon, with only a few documented cases reported in the literature. Second, in the case of large gastric neoplasms causing intussusception, rarely the neoplasm may extend down into the duodenum and obstruct the ampulla of Vater causing acute pancreatitis.2Hsieh Y.L. Hsu W.H. Lee C.C. et al.Gastroduodenal intussusception caused by gastric gastrointestinal stromal tumor: a case report and review of the literature.World J Clin Cases. 2021; 9: 838-846Crossref Scopus (7) Google Scholar Furthermore, pyloric gland adenomas are rare gastric neoplasms that tend to be polypoid in morphology and are associated with autoimmune gastritis, predominantly occurring in female patients, as in this case.3Choi W.T. Brown I. Ushiku T. et al.Gastric pyloric gland adenoma: a multicentre clinicopathological study of 67 cases.Histopathology. 2018; 72: 1007-1014Crossref PubMed Scopus (35) Google Scholar Lastly, the traditional management for lesions causing gastroduodenal intussusception is surgical because of the risk of malignancy. However, in this case, the patient underwent successful curative and therapeutic endoscopic resection with ESD.2Hsieh Y.L. Hsu W.H. Lee C.C. et al.Gastroduodenal intussusception caused by gastric gastrointestinal stromal tumor: a case report and review of the literature.World J Clin Cases. 2021; 9: 838-846Crossref Scopus (7) Google Scholar

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