Type III gastric carcinoid tumors:
Type III gastric carcinoids are sporadic tumors, most often solitary (usually > 2 cm), occur more commonly in men, and behave more aggressively than types I and II. Unlike types 1 and II, they are not associated with hypergastrinemia. Type I gastric carcinoids are the most common type of gastric carcinoid, and occur in patients with chronic hypergastrinemia secondary to pernicious anemia or chronic atrophic gastritis. Type II is rare, and is associated with MEN1 and ZES. Gastric carcinoids should all be resected, and small lesions ( <2 cm) confined to the mucosa may be treated endoscopically with endoscopic mucosal resection (EMR) if there are only a few lesions ( <5) and if margins are histologically negative. Locally invasive lesions, or those >2 cm, should be removed by radical gastric resection and lymphadenectomy. Survival is excellent for node-negative patients (>90% 5-year survival); node-positive patients have a 50% 5-year survival. The 5-year survival for patients with type I gastric carcinoid is close to 100%; for patients with type III lesions, the 5-year survival is less than 50%. Most type III patients have nodal or distant metastases at the time of diagnosis, and some present with symptoms of carcinoid syndrome.
Watermelon stomach is best treated by:
The parallel red stripes atop the mucosal folds of the distal stomach give this rare entity its name. Histologically, gastric antral vascular ectasia (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria. Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. below). The histologic appearance can resemble portal hypertensive gastropathy, but the latter usually affects the proximal stomach, whereas watermelon stomach predominantly affects the distal stomach. Beta blockers and nitrates, useful in the treatment of portal hypertensive gastropathy, are ineffective in patients with gastric antral vascular ectasia. Patients with GAVE are usually elderly women with chronic GI blood loss requiring transfusion. Most have an associated autoimmune connective tissue disorder, and at least 25% have chronic liver disease. Nonsurgical treatment options include estrogen and progesterone, and endoscopic treatment with the neodymium yttriumaluminum garnet (Nd:YAG) laser or argon plasma coagulator. Antrectomy may be required to control blood loss, and this operation is quite effective but carries increased morbidity in this elderly patient group. Patients with portal hypertension and antral vascular ectasia should be considered for transjugular intrahepatic portosystemic shunt (TIPSS).
Gastric antral vascular ectasia (watermelon stomach):
Treatment for severe early dumping after gastrectomy that is persistent despite an antidumping diet and fiber is:
Dumping is a phenomenon consisting of a constellation of postprandial symptoms thought to be the result of the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of the pylorus or decreased gastric compliance. Early dumping occurs 15 to 30 minutes after a meal, with patients becoming diaphoretic, weak, light-headed, and tachycardic. Late dumping occurs hours later, and is due to a reactive hypoglycemia. Late dumping is relieved by the administration of sugar. The medical therapy for the dumping syndrome consists of dietary management and somatostatin analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals. Hyperosmolar liquids (eg, milk shakes) may be particularly troublesome. There is some evidence that adding dietary fiber compounds at mealtime may improve the syndrome. If dietary manipulation fails, the patient is started on octreotide, 100 μg subcutaneously twice daily. This can be increased up to 500 μg twice daily if necessary. The long -acting depot octreotide preparation is useful. Octreotide not only ameliorates the abnormal hormonal pattern seen in patients with dumping symptoms, but also promotes restoration of a fasting motility pattern in the small intestine (ie, restoration of the migrating motor complex [MMC] ). Only a very small percentage of patients with dumping symptoms ultimately require surgery. Therefore, the surgeon should not rush to re-operate on the patient with dumping syndromes.
Menetrier disease is characterized by:
There are two clinical syndromes characterized by epithelial hyperplasia and giant gastric folds: ZES and Menetrier disease. The latter is characteristically associated with proteinlosing gastropathy and hypochlorhydria. A few patients with these unusual diseases have been successfully treated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab. There may be an increased risk of gastric cancer with this disease, and gastric resection may be indicated for bleeding, severe hypoproteinemia, or cancer. The other options describe Dieulafoy lesions, watermelon stomach, and ZES, respectively.
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