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Paper text:
pyogenic granuloma was first reported as botryomycosis humaine in 1897.1 it is a benign inflammatory vascular lesion , mainly found in the skin and oral mucosa .
only a few cases of pyogenic granuloma in the gastrointestinal tract have been reported.2 a pyogenic granuloma is usually seen as a protruding polypoid lesion and occasionally as a submucosal tumor - like lesion on endoscopy .
, we reported the endosonographic findings obtained and the treatment approaches used for two patients with esophageal pyogenic granuloma .
a 58-year - old man underwent upper endoscopy as part of a medical check - up .
the upper endoscopy showed a 1-cm polypoid mass that was located just above the esophagogastric junction ( fig .
1a ) . the mass had a smooth surface and was covered with white exudates ; it did not exhibit cushion sign .
1b ) , had clear margins , and was located in the submucosa . endoscopic and eus findings suggested possibility of an inflammatory lesion such as inflammatory fibrinoid polyp .
the patient wanted to remove the tumor strongly and then endoscopic resection was planned without biopsy . for endoscopic resection ,
histological examination showed edematous granulation tissue containing numerous capillaries with acute and chronic inflammatory cell infiltration ( fig .
a 54-year - old man visited our hospital because of the incidental detection of a polypoid lesion in the esophagus during a medical check - up .
the patient was asymptomatic , and abnormalities were not found during his physical and laboratory examinations .
the upper endoscopy showed a 0.5-cm reddish polypoid lesion located 30 cm from the incisor teeth ( fig .
eus showed that the lesion was homogeneously hyperechogenic , had clear margins , and was located in the lamina propria ( fig .
histological analysis showed that the resected polyp was composed of abundant capillaries that were lined with endothelial cells ( fig .
the histological features were consistent with those of pyogenic granuloma . recurrence was not observed during the follow - up endoscopy performed 6 months later .
a 58-year - old man underwent upper endoscopy as part of a medical check - up .
the upper endoscopy showed a 1-cm polypoid mass that was located just above the esophagogastric junction ( fig .
1a ) . the mass had a smooth surface and was covered with white exudates ; it did not exhibit cushion sign .
1b ) , had clear margins , and was located in the submucosa . endoscopic and eus findings suggested possibility of an inflammatory lesion such as inflammatory fibrinoid polyp .
the patient wanted to remove the tumor strongly and then endoscopic resection was planned without biopsy . for endoscopic resection ,
histological examination showed edematous granulation tissue containing numerous capillaries with acute and chronic inflammatory cell infiltration ( fig .
a 54-year - old man visited our hospital because of the incidental detection of a polypoid lesion in the esophagus during a medical check - up .
the patient was asymptomatic , and abnormalities were not found during his physical and laboratory examinations .
the upper endoscopy showed a 0.5-cm reddish polypoid lesion located 30 cm from the incisor teeth ( fig .
eus showed that the lesion was homogeneously hyperechogenic , had clear margins , and was located in the lamina propria ( fig .
histological analysis showed that the resected polyp was composed of abundant capillaries that were lined with endothelial cells ( fig .
pyogenic granuloma is a common lesion in the skin and oral mucosa , but rarely found in the alimentary tract.3 only 42 cases of pyogenic granuloma in the alimentary tract have been reported to date ; the granuloma was located in the esophagus in 23 of these cases.2 - 6 the incidence rate is the same regardless of the gender and age of the patient.4 currently , the etiologic factors suggested for pyogenic granuloma are infection , mechanical trauma , chemical irritation , pregnancy , and hormonal mechanisms that induce reactive inflammatory and abnormal vascular response.7,8 however , the exact etiology is still unknown .
thirty percent of the patients with esophageal pyogenic granulomas are asymptomatic and the remainder experience diverse symptoms such as dysphagia , epigastric discomfort , and soreness.5 on endoscopic analysis , such granulomas are seen as protruding tumors or occasionally as submucosal tumor - like lesions .
their diameters are less than 20 mm , and they are pale pink to dark red in color.4 the surface of these lesions were usually soft and were sometimes accompanied by exudates .
our patients had submucosal tumor - like lesions , and therefore , we performed eus .
eus showed that the patients had lesions that were homogeneously hyperechogenic , had clear borders , and were located in the lamina propria or submucosa .
it is thought that the hyperechogenicity reflects the proliferation of blood vessels in lesions like hemangiomas.9 these eus features would be helpful in the differential diagnosis of esophageal submucosal tumor - like lesions , such as gastrointestinal stromal tumor , leiomyoma , lipoma , granular tumor , and duplication cyst . in case 2 , bleeding occurred by forceps biopsy and then epinephrine was injected to stop the bleeding . since pyogenic granuloma is a highly vascular lesion , massive bleeding is expected after biopsy . therefore ,
if there is a possibility of pyogenic granuloma in esophageal submucosal tumor - like lesions by the above mentioned eus findings , we could avoid endoscopic biopsy for histological diagnosis .
emr and endoscopic snare polypectomy are the most favorable treatment options for esophageal pyogenic granulomas.3,6 in our patients , the lesions were completely resected using traditional emr or emr with a ligation device .
pyogenic granuloma is histologically characterized by capillary hemangiomas with lobulated proliferation in the edematous stroma .
the granuloma is consisted of numerous newly formed capillaries of variable sizes , with the infiltration of acute and chronic inflammatory cells.3 kaposi 's sarcoma must be included in the differential diagnosis in such cases .
kaposi 's sarcoma is suspected more often than pyogenic granuloma when a patient has immunosuppression due to conditions such as aids or transplantation ; it is also suspected to a greater extent when spindle cells and eosinophilic globules are observed during histological analysis.10 in summary , esophageal pyogenic granuloma is a rare submucosal tumor - like polypoid lesion .
on eus , it appears as a homogeneously hyperechoic lesion that has clear borders and is located in the lamina propria or submucosa .
pyogenic granuloma is a benign inflammatory vascular lesion , mainly found in the skin and oral mucosa 
 . a few cases of pyogenic granuloma in the gastrointestinal tract have been reported , and the esophagus was the main site in these cases . 
 these patients were diagnosed with pyogenic granuloma after they underwent upper endoscopy and biopsy . 
 endoscopic resection is a favorable treatment option for esophageal pyogenic granuloma . 
 recently , we observed characteristic endosonographic findings in two cases with esophageal pyogenic granuloma , which were then treated successfully by endoscopic resection .