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June 10, 2019

Image challenge: You just got burned! What is wrong with this gastric pouch?

What caused an abnormal color to appear on the gastric pouch epithelium of three patients?

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Gastroenterology clinical image challenge: We describe three unique presentations of patients with a prior history of Roux-en-Y gastric bypass who were referred for endoscopic treatment of weight regain. All of the patients had failed prior attempts at lifestyle modifications and pharmacologic weight loss treatment. On physical examination, their body mass indices ranged from 27 to 30 kg/m2, but examination and complete laboratory evaluation, including thyroid-stimulating hormone, were otherwise normal. During the first upper gastrointestinal esophagogastroduodenoscopies, the pouch and the gastrojejunal anastomosis (GJA) were characterized by healthy appearing mucosa. In all three cases, the pouch size measured between 3 and 5 cm and the GJA was dilated, with diameters of more than 20 mm (figure). Laser resurfacing of the stoma by argon plasma coagulation (APC) at 0.8 L/min and 70 watts was successfully performed in a 1-cm concentric ring fashion around the gastric side of the GJA (figure). Three months after the initial APC, the patients returned for reevaluation. The pouch mucosa again seemed to be normal, but there was persistent, albeit improved, dilation of the GJA. Repeat APC sessions were performed without any adverse events. 

On their next follow-up esophagogastroduodenoscopies, all patients were noted to have an abnormal color of approximately 25% of their gastric pouch epithelium, which seemed to be more similar to the esophageal epithelium (figure). The GJAs remained dilated, measuring  more than 14 mm, and their third APC sessions were performed (figure). The patients did well after the procedures, with significant weight loss. A one-year follow-up endoscopy showed a 10-mm GJA, but the gastric pouch was now approximately 80% to 100% covered with this abnormal epithelium (figure). A forceps biopsy was performed for histologic evaluation (figure).

What is the histopathologic diagnosis of this finding?

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.

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