Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Endoscopic ultrasound for the characterization of subepithelial lesions of the upper gastrointestinal tract

INTRODUCTION

A subepithelial mass or a bulge encountered during an endoscopy can arise from within any layer of the gastrointestinal tract wall (intramural) or outside of the wall (extramural). They are usually found incidentally during routine imaging with barium contrast radiography or endoscopy. The differential diagnosis includes a number of benign and malignant non-epithelial gastric wall tumors, intramural vessels, and extrinsic compression from extramural structures.

Endoscopy alone cannot accurately distinguish between intramural and extramural lesions [1]. By contrast, endoscopic ultrasonography (EUS) has provided a major breakthrough for characterizing such masses. This topic review will provide an overview of the most common subepithelial lesions that can be identified endosonographically. Discussions on the individual lesions are also available on the corresponding topic reviews.

GENERAL PRINCIPLES FOR IMAGING

EUS provides a number of methods for characterizing subepithelial lesions:

  • It provides an understanding of whether the lesion arises from the bowel wall (intramural) or from a structure outside the bowel wall (extramural) compressing the gastrointestinal wall. Extramural lesions may be a normal adjacent structure (eg, spleen, aorta, gallbladder) or pathologic structures (eg, splenic artery aneurysm, cyst, tumor). Rarely, the distinction between an intra- and extramural lesion may be difficult when there is invasion into the gastrointestinal wall.
  • It can determine the originating layer of intramural lesions, an important clue for achieving a diagnosis (table 1). Stromal cell tumors, for example, can typically be seen as evolving from the muscularis propria or muscularis mucosa, whereas lipomas typically evolve from the submucosa.
  • The echogenicity, vascularity, margins, size of the lesion, and absence or presence of adjacent lymph nodes also help to narrow the differential diagnosis.
  • EUS-guided fine-needle aspiration or trucut biopsy of the lesion may be helpful in some settings. (See "Endoscopic ultrasound-guided fine-needle aspiration biopsy in the gastrointestinal tract" and "Endoscopic ultrasound guided trucut biopsy".)

Technical considerations — The following are basic principles that should be understood by endosonographers attempting to visualize subepithelial lesions.

                                        

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2014. | This topic last updated: Jan 18, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Hwang JH, Saunders MD, Rulyak SJ, et al. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastrointest Endosc 2005; 62:202.
  2. Cantor MJ, Davila RE, Faigel DO. Yield of tissue sampling for subepithelial lesions evaluated by EUS: a comparison between forceps biopsies and endoscopic submucosal resection. Gastrointest Endosc 2006; 64:29.
  3. Lee CK, Chung IK, Lee SH, et al. Endoscopic partial resection with the unroofing technique for reliable tissue diagnosis of upper GI subepithelial tumors originating from the muscularis propria on EUS (with video). Gastrointest Endosc 2010; 71:188.
  4. Hunt GC, Smith PP, Faigel DO. Yield of tissue sampling for submucosal lesions evaluated by EUS. Gastrointest Endosc 2003; 57:68.
  5. Rodriguez SA, Faigel DO. Endoscopic diagnosis of gastrointestinal stromal cell tumors. Curr Opin Gastroenterol 2007; 23:539.
  6. Yahagi N. Is esophageal endoscopic submucosal dissection an extreme treatment modality, or can it be a standard treatment modality? Gastrointest Endosc 2008; 68:1073.
  7. Probst A, Golger D, Arnholdt H, Messmann H. Endoscopic submucosal dissection of early cancers, flat adenomas, and submucosal tumors in the gastrointestinal tract. Clin Gastroenterol Hepatol 2009; 7:149.
  8. Lee IL, Lin PY, Tung SY, et al. Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer. Endoscopy 2006; 38:1024.
  9. Park YS, Park SW, Kim TI, et al. Endoscopic enucleation of upper-GI submucosal tumors by using an insulated-tip electrosurgical knife. Gastrointest Endosc 2004; 59:409.
  10. Polkowski M, Bergman JJ. Endoscopic ultrasonography-guided biopsy for submucosal tumors: needless needling? Endoscopy 2010; 42:324.
  11. Watson RR, Binmoeller KF, Hamerski CM, et al. Yield and performance characteristics of endoscopic ultrasound-guided fine needle aspiration for diagnosing upper GI tract stromal tumors. Dig Dis Sci 2011; 56:1757.
  12. Hoda KM, Rodriguez SA, Faigel DO. EUS-guided sampling of suspected GI stromal tumors. Gastrointest Endosc 2009; 69:1218.
  13. Kojima T, Takahashi H, Parra-Blanco A, et al. Diagnosis of submucosal tumor of the upper GI tract by endoscopic resection. Gastrointest Endosc 1999; 50:516.
  14. Karaca C, Turner BG, Cizginer S, et al. Accuracy of EUS in the evaluation of small gastric subepithelial lesions. Gastrointest Endosc 2010; 71:722.
  15. Motoo Y, Okai T, Ohta H, et al. Endoscopic ultrasonography in the diagnosis of extraluminal compressions mimicking gastric submucosal tumors. Endoscopy 1994; 26:239.
  16. Pidhorecky I, Cheney RT, Kraybill WG, Gibbs JF. Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management. Ann Surg Oncol 2000; 7:705.
  17. Suster S. Gastrointestinal stromal tumors. Semin Diagn Pathol 1996; 13:297.
  18. Miettinen M, Lasota J. Gastrointestinal stromal tumors--definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch 2001; 438:1.
  19. Graadt van Roggen JF, van Velthuysen ML, Hogendoorn PC. The histopathological differential diagnosis of gastrointestinal stromal tumours. J Clin Pathol 2001; 54:96.
  20. Chak A, Canto MI, Rösch T, et al. Endosonographic differentiation of benign and malignant stromal cell tumors. Gastrointest Endosc 1997; 45:468.
  21. Krinsky ML, Savides TJ, Behling C. Ex-vivo correlation of endosonographic features with pathologic findings in gastric stromal tumors. Gastrointest Endosc 2001; 53:AB170.
  22. Palazzo L, Landi B, Cellier C, et al. Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours. Gut 2000; 46:88.
  23. Ando N, Goto H, Niwa Y, et al. The diagnosis of GI stromal tumors with EUS-guided fine needle aspiration with immunohistochemical analysis. Gastrointest Endosc 2002; 55:37.
  24. Hunt GC, Rader AE, Faigel DO. A comparison of EUS features between CD-117 positive GI stromal tumors and CD-117 negative GI spindle cell tumors. Gastrointest Endosc 2003; 57:469.
  25. Demetri GD, Benjamin RS, Blanke CD, et al. NCCN Task Force report: management of patients with gastrointestinal stromal tumor (GIST)--update of the NCCN clinical practice guidelines. J Natl Compr Canc Netw 2007; 5 Suppl 2:S1.
  26. Maderal F, Hunter F, Fuselier G, et al. Gastric lipomas--an update of clinical presentation, diagnosis, and treatment. Am J Gastroenterol 1984; 79:964.
  27. Nakamura S, Iida M, Suekane H, et al. Endoscopic removal of gastric lipoma: diagnostic value of endoscopic ultrasonography. Am J Gastroenterol 1991; 86:619.
  28. Savides TJ. Endoscopic Ultrasonography. In: Gastrointestinal submucosal masses, 1, Gress F (Eds), Blackwell Science, 2001.
  29. Murray MA, Kwan V, Williams SJ, Bourke MJ. Detachable nylon loop assisted removal of large clinically significant colonic lipomas. Gastrointest Endosc 2005; 61:756.
  30. Raju GS, Gomez G. Endoloop ligation of a large colonic lipoma: a novel technique. Gastrointest Endosc 2005; 62:988.
  31. Lee SH, Park JH, Park do H, et al. Endoloop ligation of large pedunculated submucosal tumors (with videos). Gastrointest Endosc 2008; 67:556.
  32. Godwin JD 2nd. Carcinoid tumors. An analysis of 2,837 cases. Cancer 1975; 36:560.
  33. Nakamura S, Iida M, Yao T, Fujishima M. Endoscopic features of gastric carcinoids. Gastrointest Endosc 1991; 37:535.
  34. Soga J. Histogenesis of carcinoids in relation to ordinary carcinomas. Acta Med Biol (Niigata) 1982; 30:17.
  35. Tada S, Iida M, Yao T, et al. Granular cell tumor of the esophagus: endoscopic ultrasonographic demonstration and endoscopic removal. Am J Gastroenterol 1990; 85:1507.
  36. Martin RC, Stulc JP. Multifocal granular cell tumor of the biliary tree: case report and review. Gastrointest Endosc 2000; 51:238.
  37. Orlowska J, Pachlewski J, Gugulski A, Butruk E. A conservative approach to granular cell tumors of the esophagus: four case reports and literature review. Am J Gastroenterol 1993; 88:311.
  38. Narra SL, Tombazzi C, Datta V, Ismail MK. Granular cell tumor of the esophagus: report of five cases and review of the literature. Am J Med Sci 2008; 335:338.
  39. Onoda N, Kobayashi H, Satake K, et al. Granular cell tumor of the duodenum: a case report. Am J Gastroenterol 1998; 93:1993.
  40. White JG, el-Newihi HM, Hauser CJ. Granular cell tumor of the stomach presenting as gastric outlet obstruction. Am J Gastroenterol 1994; 89:2259.
  41. Palazzo L, Landi B, Cellier C, et al. Endosonographic features of esophageal granular cell tumors. Endoscopy 1997; 29:850.
  42. Norberto L, Urso E, Angriman I, et al. Yttrium-aluminum-garnet laser therapy of esophageal granular cell tumor. Surg Endosc 2002; 16:361.
  43. Geller A, Wang KK, DiMagno EP. Diagnosis of foregut duplication cysts by endoscopic ultrasonography. Gastroenterology 1995; 109:838.
  44. Woolfolk GM, McClave SA, Jones WF, et al. Use of endoscopic ultrasound to guide the diagnosis and endoscopic management of a large gastric duplication cyst. Gastrointest Endosc 1998; 47:76.
  45. Faigel DO, Burke A, Ginsberg GG, et al. The role of endoscopic ultrasound in the evaluation and management of foregut duplications. Gastrointest Endosc 1997; 45:99.
  46. Coit DG, Mies C. Adenocarcinoma arising within a gastric duplication cyst. J Surg Oncol 1992; 50:274.
  47. Van Dam J, Rice TW, Sivak MV Jr. Endoscopic ultrasonography and endoscopically guided needle aspiration for the diagnosis of upper gastrointestinal tract foregut cysts. Am J Gastroenterol 1992; 87:762.
  48. Wildi SM, Hoda RS, Fickling W, et al. Diagnosis of benign cysts of the mediastinum: the role and risks of EUS and FNA. Gastrointest Endosc 2003; 58:362.
  49. Banner K, Helft S, Kadam J, et al. An unusual cause of dysphagia in a young woman: esophageal duplication cyst. Gastrointest Endosc 2008; 68:793.
  50. Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Gastric aberrant pancreas: EUS analysis in comparison with the histology. Gastrointest Endosc 1999; 49:493.
  51. Lucena JF, Alvarez OA, Gross GW. Endoscopic resection of heterotopic pancreas of the minor duodenal papilla: case report and review of the literature. Gastrointest Endosc 1997; 46:69.
  52. Kim JY, Lee JM, Kim KW, et al. Ectopic pancreas: CT findings with emphasis on differentiation from small gastrointestinal stromal tumor and leiomyoma. Radiology 2009; 252:92.
  53. Minamoto T, Ueda H, Ooi A, et al. A limitation of endoscopic ultrasound: an unusual case of early gastric cancer overlying a pancreatic rest. Am J Gastroenterol 1991; 86:622.
  54. Shim CS, Jung IS. Endoscopic removal of submucosal tumors: preprocedure diagnosis, technical options, and results. Endoscopy 2005; 37:646.
  55. Soon MS, Lin OS. Inflammatory fibroid polyp of the duodenum. Surg Endosc 2000; 14:86.
  56. American Gastroenterological Association Institute. American Gastroenterological Association Institute medical position statement on the management of gastric subepithelial masses. Gastroenterology 2006; 130:2215.