GI Endoscopy · 2 min read
Ménétrier Disease: A Diagnostic Challenge of Enlarged Gastric Folds
Experienced teaching points
Clinical Pearls
- Keep Ménétrier disease in the differential for giant gastric folds that do not flatten with air insufflation.
- EUS helps confirm intact muscularis propria and lowers the likelihood of infiltrative malignancy before biopsy.
- Deep or full-thickness mucosal sampling is required because the diagnostic histology sits deeper than a superficial pinch biopsy.
- Correct recognition prevents misclassification as gastric cancer or lymphoma and avoids unnecessary oncologic pathways.
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| Patient: | 76-year-old male with anemia |
| Indication: | Repeat EGD with EUS for a large circumferential ulcerated mass at the gastric cardia |
| Final diagnosis: | Ménétrier disease diagnosed by EUS plus deep targeted biopsies |
Endoscopic Findings
- EGD demonstrated a fundal lesion around the cardia with enlarged and edematous rugal folds.
- The folds failed to flatten with air insufflation and were covered by tenacious adherent mucus.
- EUS showed intact muscularis propria without invasion into the muscular layer around the fundus.
Endoscopic Technique
- Repeat EGD was performed for reassessment of the cardia and fundus.
- A radial echoendoscope was advanced after EGD for ultrasound evaluation.
- The gastric fundus was examined with balloon inflation at the tip of the echoendoscope to optimize visualization.
- Multiple deep biopsies of the lesion were obtained for histopathology.
Discussion
Ménétrier disease is a rare acquired hypertrophic gastropathy that typically affects men at a mean age of about 55 years. Clinical manifestations include progressive abdominal pain, nausea, vomiting, and peripheral edema. The disease is characterized by giant rugal folds of the body and fundus, hypochlorhydria or achlorhydria, excess gastric mucus production, and protein-losing enteropathy.
Endoscopically, the hallmark is markedly enlarged and edematous rugal folds that do not flatten with air insufflation and are often covered by tenacious mucus. Histology shows massive foveolar hyperplasia, tortuosity and cystic dilation of glands, smooth muscle hyperplasia, and atrophy of oxyntic mucosa with reduced parietal and chief cells. Because these changes predominantly involve deeper mucosa, deep or full-thickness biopsies are required for diagnosis.
Enlarged gastric folds also raise concern for infiltrative adenocarcinoma, signet-ring cell carcinoma, and gastric lymphoma. The differential includes Helicobacter pylori gastritis, Zollinger-Ellison syndrome, portal hypertensive gastropathy, and gastric polyposis syndromes. In this case, intact muscularis propria on EUS plus deep mucosal sampling established Ménétrier disease and avoided misclassification as an infiltrative neoplasm.
References
- Richer R, Barbu ST. Ménétrier disease: A rare cause of protein-losing gastropathy. Gastrointest Endosc. 2018;88(4):629.
- Meuwissen SG, Hasler WL, van der Waaij LA. Ménétrier disease: Clinical, endoscopic, and histopathological features. World J Gastroenterol. 2011;17(3):329-335.
- Komorowski RA, Caya JG. Ménétrier disease: A clinicopathologic study of 16 patients. Hum Pathol. 1984;15(3):264-272.
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