A 62-year-old man with compensated liver cirrhosis (Child-Pugh score: class A) was referred for further evaluation of a 5 cm nodular lesion in the gastric fundus, seen in Computed Tomography scan. He had no history of variceal bleeding. Esophagogastroduodenoscopy revealed a large prominent submucosal protuberance in the gastric fundus, on retroflexed view (Fig.1) covered by normal mucosa.
Figure 1 (A) Figure 1 (B)
Figures 1 (upper endoscopy): Large prominent submucosal protuberance with smooth mucosal surface (A) located in the gastric fundus (on retroflexed view, B), “soft” on palpation with biopsy forceps.
The structure did not have a bluish hue or serpiginous course characteristic of gastric varices, but retreated when pressed by a biopsy forceps. Esophageal varices were not seen. The diagnosis was uncertain. The differential diagnosis included GIST, carcinoid tumor, lipoma, and atypical gastric varix. We performed endoscopic ultrasonography (EUS), which unveiled an anechoic tubular structure, within the third gastric wall layer (sub-mucosa), with power Doppler signal (Fig.2), consistent with atypical isolated gastric varix (IGV) type 1, Sarin Classification. Prominent gastric collateral circulation was also observed.
Gastric varices may appear similar to enlarged gastric folds and submucosal neoplasms at endoscopy. Tissue sampling is risky and the diagnosis can be challenging. EUS is a useful and accurate noninvasive method to differentiate these entities.(1) Doppler EUS enables the visualization of esophagogastric varices and other venous collaterals in patients with portal hypertension, and can be useful to assess the patency of the portal venous system.(2,3) In the present case, the diagnosis of atypical isolated gastric varix was suspected due to the history of cirrhosis. However, the occurrence of a large single gastric varix non-associated with esophageal lesion is unusual in cirrhotic patients. Also, the endoscopic image was not typical of a gastric varix. We highlight that EUS is an excellent tool to obtain high quality imaging of the pancreas. The possibility of isolated gastric varix should be considered for a nodular lesion seen in the gastric fundus on endoscopy, especially if history or clinical signs of chronic liver disease.
Figure 2 (A)
Figure 2 (B)
Figures 2 (EUS, fundus): Anechoic vascular structure situated in the submucosal layer (A) with power Doppler flow (B) suggestive of isolated gastric varix (IGV) type 1, Sarin Classification.
1 Seicean A. Endoscopic ultrasound in the diagnosis and treatment of upper digestive bleeding: a useful tool. J Gastrointestin Liver Dis. 2013;22(4):465-9.
2 Garcia-Pagán JC, Barrufet M, Cardenas A, Escorsell A. Management of Gastric Varices. Clin Gastroenterol Hepatol. 2013 Jul 27.
3 Bissonnette J, Paquin S, Sahai A, Pomier-Layrargues G. Usefulness of endoscopic ultrasonography in hepatology. Can J Gastroenterol. 2011 Nov;25(11):621-5.
Teresa Pinto Pais (1) Luísa Proença (1) Sónia Fernandes (1) João Carvalho (1)
(1) Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Gaia, Portugal