Clinical Pearls & Morning Reports
Published October 12, 2022
Although gastric cancer is uncommon in the United States, it is the fifth leading cause of cancer-specific death worldwide, with more than 768,000 deaths in 2020. Read the NEJM Case Records of the Massachusetts General Hospital here.
Q: Can eosinophilic gastroenteritis affect the muscularis propria layer of the stomach?
A: Eosinophilic gastroenteritis is an increasingly recognized entity that is characterized by eosinophilic infiltration of the gastrointestinal tract. Eosinophilic gastroenteritis can affect any layer of the gastrointestinal lining, including the muscularis propria layer. Antral wall thickening can also occur and may result in gastric-outlet obstruction. However, eosinophilic gastroenteritis is most commonly manifested by mucosal disease; most cases that involve the muscularis propria layer are associated with peripheral eosinophilia.
Q: What type of gastric-wall thickening is common in gastric sarcoidosis?
A: Sarcoidosis is a systemic disease that is identified by the presence of noncaseating granulomas in involved tissues. The stomach is the most frequently involved gastrointestinal luminal organ. Fifty-eight percent of patients with gastric sarcoidosis present with extensive, diffuse infiltration of the gastric wall. Gastric sarcoidosis typically develops in patients who are 20 to 50 years of age.
A: Beyond upper endoscopy and imaging of the chest, abdomen, and pelvis, accurate staging of gastric cancer often requires that diagnostic laparoscopy be performed to examine the peritoneal surfaces and to obtain cytologic washing specimens. Several series have shown that when there is evidence that the tumor has invaded the submucosa or a deeper layer on endoscopic ultrasonography and there is no evidence of metastatic disease on CT, the risk of occult peritoneal disease is 20 to 30%.
A: Gastric adenocarcinoma frequently takes the form of an ulcerated, discrete mass. However, a morphologic variant of diffuse gastric cancer — linitis plastica — can cause gastric-wall thickening. Linitis plastica is associated with scirrhous or fibrous stroma that results from abnormal growth of submucosal connective tissue. The abnormal stroma causes hypertrophy of the gastric muscularis propria and subserosal thickening. These changes result in diffuse gastric-wall thickening that often starts at the antrum, but enlargement of the gastric folds can occur as well. Malignant infiltration of the entire antral wall disrupts the neurocircuitry and muscular contractions that are required for gastric emptying. This process initially mimics gastroparesis, with retention of solid food and nausea, but prokinetic treatments are ineffective because damage to the muscularis propria prevents these agents from effectively triggering antral contractions. Liquids are initially tolerated because they are emptied passively. However, progressive antral disease marks a transition from gastroparesis to gastric-outlet obstruction, and liquids are no longer tolerated. Patients with linitis plastica frequently present with advanced disease.