Gastric linitis plastica with autoimmune pancreatitis diagnosed by an endoscopic ultrasonography-guided fine-needle biopsy: A case report

Figure 1 An endoscopic examination of gastric linitis plastica. A: Endoscopic findings showed giant gastric folds and reddish mucosa; however, no epithelial changes were observed. The gastric lumen was not distensible by air inflation; B: Seven specimens were obtained from the gastric mucosa, none of which showed malignancy.

Figure 2 Computed tomography and 18F-Fluorodeoxyglucose-positron emission tomography/computed tomography findings. A: Contrast-enhanced computed tomography (CT) showed thickening of the wall of the gastric body; B: CT showed the diffuse enlargement of the pancreas and peripancreatic rim (arrowheads); C and D: Fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) showed the accumulation of FDG within both the gastric wall (SUV_max: 19.2) and pancreas.

Figure 3 Endoscopic ultrasonography and endoscopic ultrasonography-guided fine-needle biopsy findings. A: Under endoscopic ultrasonography (EUS), the third layer representing the submucosa (arrowhead) and the fourth layer representing the muscularis propria (arrow) were thickened; B: An EUS-fine-needle biops (FNB) of the thickened gastric wall was performed with a 19-gauge needle; C: EUS revealed hyperechoic spots in the diffuse hypoechoic pancreatic parenchymal and duct-penetrating sign (red arrow).

Figure 4 Histopathological specimen obtained by an endoscopic ultrasonography-guided fine-needle biopsy of the thickened gastric wall. A: Within the intricate muscularis propria, fibroblasts were proliferating, while a few scattered cells suspected of malignancy were seen; B: Poorly differentiated adenocarcinoma cells were seen within the deeper portion of the hyperplastic mucosa (arrowhead). The black scale bar represents 250 μm.

Figure 5 Endoscopic and computed tomography findings after the start of chemotherapy. A and B: After the start of chemotherapy, the endoscopic findings, such as the giant folds, were improved, and the gastric lumen became distensible, which allowed for duodenoscopy; C: Chemotherapy improved the computed tomography findings of the thickened gastric wall and diffuse enlargement of the pancreas.

Figure 6 Serum levels of both carbohydrate antigen 19-9 and immunoglobulin-G4 improved during chemotherapy. CA19-9: Carbohydrate antigen 19-9; IgG4: Immunoglobulin-G4; FOLFOX: 5-fluorouracil, leucovorin and oxaliplatin; PTX: Paclitaxel; RAM: Ramucirumab.