ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions

Abstract

Subepithelial lesions (SEL) of the GI tract represent a mix of benign and potentially malignant entities including tumors, cysts, or extraluminal structures causing extrinsic compression of the gastrointestinal wall. SEL can occur anywhere along the GI tract and are frequently incidental findings encountered during endoscopy or cross-sectional imaging. This clinical guideline of the American College of Gastroenterology was developed using the Grading of Recommendations Assessment, Development, and Evaluation process and is intended to suggest preferable approaches to a typical patient with a SEL based on the currently available published literature. Among the recommendations, we suggest endoscopic ultrasound (EUS) with tissue acquisition to improve diagnostic accuracy in the identification of solid nonlipomatous SEL and EUS fine-needle biopsy alone or EUS fine-needle aspiration with rapid on-site evaluation sampling of solid SEL. There is insufficient evidence to recommend surveillance vs resection of gastric gastrointestinal stromal tumors (GIST) <2 cm in size. Owing to their malignant potential, we suggest resection of gastric GIST >2 cm and all nongastric GIST. When exercising clinical judgment, particularly when statements are conditional suggestions and/or treatments pose significant risks, health-care providers should incorporate this guideline with patient-specific preferences, medical comorbidities, and overall health status to arrive at a patient-centered approach.

Gastric Glomus Tumors: The Roles of Endoscopic Ultrasound and Shared Decision-Making

“…Not only can EUS assist with differentiating GGT from other gastric tumor types, but it also allows for accurate size and depth measurements and evaluation of regional lymphadenopathy for purposes of staging [2]. The differential diagnosis for subepithelial lesions (SELs) of the GI tract includes but is not limited to GGT, gastrointestinal stromal tumors, leiomyoma, neuroendocrine tumor, lymphoma, granular cell tumor, inflammatory fibroid polyp, lipoma, Brunner gland hyperplasia, duplication cyst, pancreatic rests, lymphangioma, and metastasis [3, 7]. Since clinical, radiologic, and endoscopic findings of GGTs are nonspecific, biopsy with subsequent immunohistochemistry is required for definitive diagnosis [5].…”

“…Universal features to characterize malignant GGTs have not been established, which complicates decision-making regarding definitive management [9]. However, EUS findings which have been previously identified as being associated with malignancy in gastrointestinal SELs (none of which were present in the patient) include heterogeneous echotexture, large size (greater than 3.0–5.0 cm), and irregular margins [7]. Additional features suggestive of malignancy include deep-seated lesions of size greater than 2.0 cm, atypical mitotic figures, and moderate-to-high nuclear grade [2, 10].…”

“…While age alone is not considered a contraindication to laparoscopic procedures, patients of age above 70 years with hypertension were found to have higher rates of postoperative complications in a retrospective analysis of 632 patients who underwent laparoscopic assisted gastrectomy [13]. Although there are many potential endoscopic techniques for resection of gastric SELs, including endoscopic full-thickness resection, endoscopic submucosal dissection, endoscopic submucosal resection, and submucosal tunneling with endoscopic resection, their widespread use has been limited by technical difficulty, availability primarily at specialized centers, and lack of prospective data evaluating efficacy and safety [2, 7, 11]. Additionally, there are several potential complications of these endoscopic techniques when utilized for the management of gastric SELs, including but not limited to bleeding, perforation, and incomplete resection [2, 12].…”

Glomus Tumor of the Stomach Presenting With Upper Gastrointestinal Bleeding: A Case Report

“…The American College of Gastroenterology recently published guidelines recom mending EUS with tissue acquisition via fineneedle biopsy alone or fineneedle aspiration with rapid onsite evaluation to improve diagnostic accuracy in identifying solid non lipomatous subepithelial lesions. 16 A EUSguided biopsy is associated with the risk of bleeding and inadequate tissue acquisition. 6,17 The radiological findings described above may be seen to a certain extent in various hypervascular gastric tumors such as GIST and neuroendocrine tumors.…”

Omental patch-assisted endoscopic closure of the transmural defect after endoscopic removal of a 40-mm gastric gastrointestinal stromal tumor

“…No adverse events occurred. Endoscopic resection of gastric GISTs is considered a valid and safe alternative to surgery [1,2]. A potential limitation of this technique may be the challenge of closing a wide full-thickness defect.…”