S6437 Beneath the Surface of a “Leather Bottle Stomach”: Atypical Fatal Presentation of Linitis Plastica and Progressive Esophageal Dysphagia

Introduction: Gastric Linitis Plastica or “Leather Bottle” is a term used to describe the gross appearance of the stomach in the setting of extensive infiltration of cancer cells. Case Description/Methods: Seventy-eight-year-old woman presented with a significant history of worsening dysphagia to solids and liquids and 30 lbs. weight loss over the past 3 months. She was evaluated by our gastroenterology team and underwent an upper endoscopy which was normal and didn’t show any concerning features. Biopsies were done to rule out Eosinophilic Esophagitis (EoE) and were negative. Computed tomography (CT) of the abdomen and pelvis revealed Nonspecific thickening of the gastroesophageal junction with soft tissue extending into the retroperitoneum involving the left adrenal gland and left renal pedicle with circumferential wall thickening of the proximal and mid stomach, in addition to prominent retroperitoneal lymphadenopathy. Our Advanced Gastroenterology team were involved and planned for endoscopic ultrasound (EUS) which showed reduced distensibility of the stomach and this was apparent mainly on retroflexion as it was extremely challenging, with thickening of gastric folds in the body region highly concerning for linitis plastica, biopsies were performed. EUS revealed severe diffuse thickening and distortion of gastric walls with few suspicious hypoechoic lymph nodes. Fine needle biopsies (FNB) were performed. Stomach biopsies were positive for Helicobacter pylori gastritis, Biopsies from the gastric wall and lymph nodes were both positive for metastatic poorly differentiated adenocarcinoma. The patient followed up with oncology with a plan to start chemotherapy; she then developed an acute ischemic stroke and ultimately passed away. Discussion: Dysphagia and weight loss are highly concerning for possible malignancy. The association between dysphagia and linitis plastica is still unclear, and very rarely reported for dysphagia to be the presenting symptom. Upper endoscopy is the main diagnostic approach with detailed examination that could reveal features of decreased distensibility and biopsies positive for malignant cells. It is important to be vigilant during examination of the stomach as it can be easily missed as well as maintaining a high index of clinical suspicion to pursue further diagnostic images or EUS.