ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions : Official journal of the American College of Gastroenterology | ACG

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ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions

Dhindsa, Banreet MBBS

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The American Journal of Gastroenterology 118(1):p 22, January 2023. | DOI: 10.14309/ajg.0000000000002113


After this activity, the participant will be able to utilize evidence-based practice to diagnose and manage subepithelial lesions (SEL) of the gastrointestinal tract.


A 56-year-old man with a past medical history of gastroesophageal reflux disease presented to his gastroenterologist for worsening symptoms of heartburn and new onset intermittent solid food dysphagia. He underwent esophagogastroduodenoscopy (EGD) with findings of LA grade A esophagitis and a 2.5 cm SEL in the gastric body with normal appearing overlying gastric mucosa which was biopsied. Pillow sign was negative, and mucosal biopsies showed normal gastric mucosa. Symptoms resolved on increasing pantoprazole from 40 mg once daily to twice daily. Vitals signs, physical examination, and laboratory test results were unremarkable. What is the best next step for diagnosis of this lesion?

  • A. Bite on bite biopsies
  • B. Endoscopic ultrasound guided fine needle biopsy (EUS-FNB)
  • C. EUS alone
  • D. Computerized tomography (CT) scan of the abdomen with contrast


A 76-year-old woman with a past medical history of hypertension presents for evaluation of iron deficiency anemia on routine laboratory testing. She is asymptomatic, and vital signs and physical examination are unremarkable.

Laboratory values: Hemoglobin 9.8 g/dL; Hematocrit 34.4; MCV 76.3 fL; Iron 28 mcg/dL; Transferrin 316 mg/dL; Total iron-binding capacity 442 mcg/dL; Iron saturation 6%.

She underwent EGD with findings of a 3 cm subepithelial esophageal lesion with mild erythema of overlying mucosa. Colonoscopy was unremarkable. Endoscopic ultrasound (EUS) showed a hypoechoic lesion arising from the muscularis propria. Fine needle biopsy (FNB) was performed and showed a gastrointestinal stromal tumor (GIST). She is very apprehensive about undergoing surgery. Which of the following is the best treatment for this patient?

  • A. Surgical resection
  • B. Submucosal tunneling endoscopic resection
  • C. Endoscopic mucosal resection
  • D. Surveillance imaging


Which of the following statements is correct about the management of different types of SELs?

  • A. Endoscopic submucosal dissection (ESD) is superior to band endoscopic mucosal resection (EMR) for treatment of <1 cm rectal neuroendocrine tumors.
  • B. Unroofing technique should be used to diagnose SELs when EUS with tissue acquisition is non-diagnostic
  • C. All GISTs <2 cm in size should be resected.
  • D. EMR is superior to ESD for treatment of small type 3 gastric neuroendocrine tumors.

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