Guideline:
American Gastroenterological Association Institute medical position statement on the management of gastric subepithelial masses
Bibliographic Source(s)
- Hwang JH Kimmey MB. American Gastroenterological Association Institute medical position statement on the management of gastric subepithelial masses. Gastroenterology 2006 Jun;130(7):2215-6. [109 references] PubMed
Guideline Status
This is the current release of the guideline.
According to the guideline developer the Clinical Practice Committee meets three times a year to review all American Gastroenterological Association Institute (AGAI) guidelines. This review includes new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.
Guideline Category
Diagnosis
Evaluation
Management
Intended Users
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
To provide recommendations concerning the diagnosis and management of gastric subepithelial masses
Target Population
Adults with gastric subepithelial masses
Interventions and Practices Considered
Diagnosis
- Endoscopy
- Endosonography
- Cross-sectional imaging (computed tomography/magnetic resonance imaging)
- Tissue diagnosis
- Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA)
- EUS-guided core needle biopsy
- Stacked forceps biopsy
- Endoscopic submucosal resection and dissection
- Differential diagnosis of lesions based on EUS features
Management
- Surgical resection
- Endoscopic resection
- Surveillance (transabdominal ultrasonography; EUS)
- Ethanol ablation (considered but not recommended)
Major Outcomes Considered
- Sensitivity specificity and accuracy of diagnostic techniques
- Complications of endoscopic and surgical procedures
- Recurrence rate
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
A literature review was conducted to identify all English-language articles relating to gastric subepithelial masses published between 1980 and 2005. A search of MEDLINE and PubMed was performed using the following key words: subepithelial tumor subepithelial mass submucosal tumor or submucosal mass. The following terms were also searched to identify additional relevant articles: gastrointestinal stromal tumor carcinoid pancreatic rest glomus tumor inclusion cyst duplication cyst leiomyoma leiomyosarcoma lymphoma lipoma inflammatory fibroid polyp and extraluminal compression. The reference lists of the articles identified in this manner were then manually searched to identify any additional references. References published only in abstract form were excluded. The present review concerns gastric subepithelial masses and therefore articles concerned solely with subepithelial masses in other parts of the gastrointestinal tract were also excluded.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The recommendations are based upon the interpretation and assimilation of scientifically valid research derived from a comprehensive review of published literature. Ideally the intent is to provide evidence based upon prospective randomized placebo-controlled trials; however when this is not possible the use of experts' consensus may occur.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
The document was approved by the American Gastroenterological Association Institute Clinical Practice and Economics Committee on January 19 2006 and by the American Gastroenterological Association Institute Governing Board on April 20 2006.
Major Recommendations
The following recommendations on the management of gastric subepithelial masses were made by the American Gastroenterological Association Institute:
Masses arising outside the gastric wall or within the wall but beneath the gastric surface epithelium are commonly found during upper gastrointestinal endoscopy although their precise incidence is unknown. Standard forceps biopsy is unlikely to provide a tissue diagnosis leading to diagnostic uncertainty for the physician and the patient. The differential diagnosis of these masses is broad and ranges from clinically insignificant to malignant conditions underlining the importance of making an accurate diagnosis.
Endoscopy alone is not reliable for detecting the etiology of a subepithelial gastric mass. Cross-sectional imaging techniques such as transabdominal ultrasonography computed tomography and magnetic resonance imaging are adequate for detecting the presence of normal or abnormal structures outside the gastric wall but do not reliably distinguish between the various causes of masses arising within the gastric wall. Furthermore when only normal structures are seen on cross-sectional imaging it is difficult to know if the subepithelial "mass" seen on endoscopy is from external compression by a normal structure or an intramural lesion that was not seen on cross-sectional imaging. In this situation endoscopic ultrasonography (EUS) should be performed to confirm that the subepithelial "mass" seen on endoscopy is indeed due to external compression by a normal structure and not from an intramural lesion that was not identified on cross-sectional imaging.
EUS is currently the most accurate imaging test for detecting the component of the gastric wall from which the mass arises and the echogenicity of the mass factors that can narrow the differential diagnosis. EUS imaging alone is not sufficient to provide an accurate diagnosis of hypoechoic intramural masses however.
Hypoechoic intramural masses are the most clinically important lesions within the gastric wall because of their malignant potential. Gastrointestinal stromal tumors carcinoid tumors lymphomas and metastases from a distant primary malignancy can have significant implications for the patient and are the main reason to pursue a tissue diagnosis of this type of mass whenever possible. Submucosal masses may be amenable to endoscopic snare resection whereas masses arising from the muscularis propria can be sampled with EUS-guided fine-needle aspiration or core biopsy. Use of immunocytochemistry is helpful in distinguishing between the potential causes of hypoechoic intramural masses. Unfortunately the true malignant potential for individual gastrointestinal stromal tumors cannot be accurately determined using current imaging and noninvasive sampling methods.
Patients with symptoms that can be attributed to the mass should undergo endoscopic or surgical resection of the mass. Current evidence does not allow making a firm recommendation on the optimal management of the patient with an incidentally detected asymptomatic gastric subepithelial mass. Options include performing no further testing or monitoring following the mass with periodic endoscopic or EUS surveillance and endoscopic or surgical resection of the mass (see table below). These management options should be discussed with the patient and whenever possible guided by EUS imaging and tissue sampling information because the clinical significance of the mass is highly variable
Summary of The Recommendations for the Management of Asymptomatic Gastric Subepithelial Masses
| No further investigation or follow-up | Follow with periodic endoscopy and/or endoscopic ultrasonography (EUS) or resection | Resection |
|---|---|---|
|
|
|
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of evidence supporting the recommendations is not specifically stated.
The recommendations are based upon the interpretation and assimilation of scientifically valid research derived from a comprehensive review of published literature. Ideally the intent is to provide evidence based upon prospective randomized placebo-controlled trials; however when this is not possible the use of experts' consensus may occur.
Potential Benefits
- Improvement in diagnostic accuracy
- Streamlining of the differential diagnoses
- Effective management
Potential Harms
- Perforation infection or hemorrhage with endoscopic ultrasonography (EUS)-guided fine needle aspiration (FNA)
- Bleeding with stacked forceps biopsy
- Perforation or bleeding with endoscopic submucosal resection (ESMR)
- Morbidity and mortality associated with surgical resection
- Bleeding and perforation with endoscopic resection
Qualifying Statements
These recommendations should not be construed as a standard of care. The AGA Institute stresses that the final decision regarding the care of the patient should be made by the physician with a focus on all aspects of the patient's current medical situation.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Bibliographic Source(s)
- Hwang JH Kimmey MB. American Gastroenterological Association Institute medical position statement on the management of gastric subepithelial masses. Gastroenterology 2006 Jun;130(7):2215-6. [109 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Gastroenterological Association Institute
Guideline Committee
American Gastroenterological Association Institute Clinical Practice Committee
Composition of Group that Authored the Guideline
Authors: Joo Ha Hwang; Michael B. Kimmey
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
According to the guideline developer the Clinical Practice Committee meets three times a year to review all American Gastroenterological Association Institute (AGAI) guidelines. This review includes new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.
Guideline Availability
Electronic copies: Available from the American Gastroenterological Association Institute (AGAI) Gastroenterology journal Web site.
Print copies: Available from the American Gastroenterological Association Institute 4930 Del Ray Avenue Bethesda MD 20814.
Availability of Companion Documents
The following is available:
- American Gastroenterological Association Institute technical review on the management of gastric subepithelial masses. Gastroenterology 2006 Jun;130(7);2217-2228.
Electronic copies: Available from the American Gastroenterological Association Institute (AGAI) Gastroenterology journal Web site.
Print copies: Available from American Gastroenterological Association Institute 4930 Del Ray Avenue Bethesda MD 20814.
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on August 9 2006.
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