An incidental gastric finding

August 26, 2015 By: Bjorn Rembacken

An incidental gastric finding

What would you diagnose in this elderly, overweight man with diabetes and iron deficiency anaemia?

The lesion in the photographs was noted in the stomach of an overweight 70-year-old man with diabetes who was undergoing gastroscopy because of iron deficiency anaemia.

 

WHAT IS YOUR ENDOSCOPIC DIAGNOSIS?

a)    Lymphangiectatic cyst

b)    Small gastrointestinal stromal tumour (GIST)

c)    Small leiomyoma

d)    Xanthelasma

e)    Small signet ring cell carcinoma

Discussion

Lymphangiectatic cysts are found in the small bowel and the pale lesion is too superficial to be anything else than a gastric xanthelasma.

Gastric xanthelasmata appear as yellowish-white plaques in the stomach, most commonly in the antrum. However, they are not exclusively found in the stomach and have also been reported in the oesophagus, small bowel and colon. A Japanese group reviewing a series of 25 colorectal xanthelasmata concluded that the histological appearance was subtly different to xanthelasmata found elsewhere and proposed that the process was secondary to a mucosal injury.1

Histologically, xanthelasmata consist of histiocytes (macrophages) in the lamina propria that are stuffed full of fat. Originally, they were thought to be caused by a local disturbance of fat metabolism because serum lipid levels are normal. However, in a Japanese series of more than 3,000 gastroscopies, xanthelasmata were found in 8% of examinations.2 These researchers confirmed the well-known link with increasing age and also described a link with Helicobacter pylori infection, gastric atrophy, and with gastric cancer. However, the lesions themselves are not thought to be premalignant.

An interesting study used a polyclonal antibody to demonstrate the presence of Helicobacter pylori in the cytoplasm of the histiocytes of the xanthelasmata.3 Subsequent immuno-electron microscopy confirmed that Helicobacters were present both on the epithelial surface and also in the phagosome of the macrophages. These findings implicate lamina proprial invasion of surface-infected H. pylori in the aetiology of gastric xanthelasmata, though I have not seen these findings replicated elsewhere.

 

References 

  1. Nakasono M, Hirokawa M, Muguruma N, et al. Colorectal xanthomas with polypoid lesion: report of 25 cases. APMIS 2004; 112: 3–10. 
  2. Sekikawa A, Fukui H, Maruo T, et al. Gastric xanthelasma may be a warning sign for the presence of early gastric cancer. J Gastroenterol Hepatol 2014; 29: 951–956. 
  3. Hori S and Tsutsumi Y. Helicobacter pylori infection in gastric xanthomas: immunohistochemical analysis of 145 lesions. Pathology International 1996; 46: 589–593. 

 

 

Answer

Correct answer: d.

 

 

About the author

Bjorn Rembacken is at Leeds Teaching Hospitals NHS Trust, Leeds, UK. He was born in Sweden and qualified from Leicester University in 1987. He undertook his postgraduate education in Leicester and in Leeds. His MD was dedicated to inflammatory bowel disease. Dr Rembacken was appointed Consultant Gastroenterologist, Honorary Lecturer at Leeds University and Endoscopy Training Lead in 2005. Follow Bjorn on Twitter @Bjorn_Rembacken

 

Comments

Pierluigi, September 02, 2015 05:51
Are there reports of bacteria in arterial xantelasmata?

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