Stomach

The sand dollar sign: a reliable EUS image to identify the excluded stomach during EUS-guided gastrogastrostomy A 69-year-old woman with a history of laparoscopic Roux-en-Y gastric bypass surgery and cholecystectomy presented with cholangitis. Laboratory investigation revealed a total bilirubin of 2.2 mg/dL and alkaline phosphatase of 647 U/L. Cross-sectional imaging suggested common bile duct stones. EUS-guided antegrade access to the common bile duct was achieved by deployment of a luminal self-expandable metal stent (LAMS) from the pouch to the remnant (excluded) stomach (A). On EUS imaging, the remnant stomach (B, C) resembles a sand dollar, a burrowing sea urchin also sometimes referred to as a sea cookie. There are many varieties, although the remnant stomach has an appearance similar to Clypeaster reticulatus (https://en.wikipedia.org/wiki/Sand_dollar) (D). In our patient, the major papilla was subsequently accessed for stone removal using a standard ERCP approach. In our experience of more than 15 gastrogastrostomies, we have found the “sand dollar sign” to be a reliable way to identify the remnant stomach by EUS imaging.

Background and Aims: An L-menthol preparation (Minclea®) (hereinafter referred to as “PO”) is used as an anti-peristaltic drug. This effect not only suppresses peristalsis but also relaxes the muscle. In the present study, we examined the impact of PO on the ability to observe the stomach on transnasal endoscopy.

[Subjects] Fifty-four patients with atrophic gastritis were sprayed with PO during routine examination with transnasal endoscopy. Their mean age was 62.1 years, and the male/female ratio was 32/22. The degree of atrophy (Kimura-Takemoto classification) was mild (C-1, C-2) in 14, moderate (C-3, O-1) in 17, and severe (O-2, O-3) in 23. Subjective symptoms were none or mild.

PO was sprayed into the pyloric antrum during peristalsis, and into the lower greater curvature of stomach when no peristalsis occurred. Extension of the gastric corpus, interval of folds in the greater curvature, and peristalsis in the pyloric antrum were compared retrospectively before and after PO spraying. The observation ability was assessed as scores from good (3) to slightly good (2) and poor (1), while the strength of peristalsis was assessed as scores from 3 (strong) to 2 (medium) and 1 (weak).