Chapter 9, Page 14  

GIANT RUGAL HYPERTROPHIES (GIANT FOLDS DISEASES, HYPERPLASTIC GASTROPATHIES) Classification of Giant Folds, with or without Associated Syndromes Giant folds are classified by the types of mucosa covering the expanded submucosal folds and the clinical settings in which they occur. The classification is shown in see Table 9-4. Literature on giant folds is confusing because some of the associated conditions or syndromes have not been rigidly defined, incomplete variants of some of the syndromes have been reported, and results of some of the published cases and series do not correlate with histologic changes. As an example, a large series of giant folds cases were defined as Menetrier's disease based only upon the combination of gross giant folds, which the authors referred to as "hypertrophic gastropathy," and hypoproteinemia, with no histologic correlation (123). Furthermore, 43 patients with this combination were compared with 47 patients who also had giant folds but who had normal serum proteins, and this group also had no histologic correlation. In this study, the authors did not include histologic analysis, because all the patients had small gastroscopic biopsies that were considered of "limited value for assessing the extent and depth of inflammation and hypertrophy." Nevertheless, histologic assessment is essential in order to determine what changes are occurring in the big folds. Recently, large bore biopsy instruments or snare biopsy instruments have been utilized for assessment (119, 120). These have the capability to amputate a full thickness chunk of mucosa, including the entire tip of a giant fold. If such instruments are used, the only limitation is histologic analysis of conditions in which irregular or focal, rather than diffuse, changes occur, because a single biopsy, even one taken with a large bore instrument, may not pick up the diagnostic area.