Case 1: 67-year-old male underwent EGD for evaluation of iron deficiency anemia, which revealed multiple large polyps in the gastric antrum. He was referred to our center for further evaluation.
Video 1: Upper endoscopy showed approximately 15 polyps in the antrum and extending into the pylorus. They were mostly pedunculated and the largest was 25mm. 8 of the largest polyps were removed with hot snare and were retrieved with Roth net. Pathology of the polyps revealed hyperplastic tissue with superficial erosions. There was no evidence of dysplasia or malignancy.
Case 2: 65-year-old female underwent EGD for evaluation of reflux symptoms, which showed a gastric pyloric mass. She was referred to us for further evaluation.
Video 2: Upper endoscopy showed a 15 mm erythematous, vascular appearing round polyp in the pre-pyloric gastric antrum. There was old and fresh blood adherent to the polyp suggestive of recent bleeding. The polyp appeared to be attached with a thin stalk. On radial EUS the pre-pyloric polyp appeared to be mucosally based with an intact submucosal layer. It was hypoechoic, heterogeneous and measured about 15 mm by 7 mm. The polyp was removed with hot snare and specimen was retrieved in a Roth net. The scope was reinserted and the base was clean without any bleeding. Pathology of this polyp showed hyperplastic tissue with no malignancy or dysplasia.
Case 3: 46 year old male with multiple co-morbidities including cirrhosis and CHF was referred to our center for evaluation of an enlarging gastric antral mass. It was initially discovered on EGD 3 year’s prior.
Video 3:Upper endoscopy showed several polyps in the pre-pyloric gastric antrum forming a polypoid mass measuring approximately 4 cm. This polypoid mass was attached to a thick stalk. There were several smaller polyps in the antrum measuring approximately 5 to 10 mm. On endoscopic ultrasonographic exam, there was a heterogeneous mass in the gastric antrum, which was mucosally based. The underlying submucosa and muscularis propria were intact. There were no peri-gastric lymph nodes. Considering the patient’s co-morbidities this mass was not resected. Biopsies were obtained from this polypoid gastric antral mass, which showed hyperplastic tissue.
Gastric polyps are found in approximately 6 percent of upper gastrointestinal endoscopic procedures in the United States. Prevalence of hyperplastic polyps varies according to the geographic regions is reported to be around 17% of gastric polyps in US. But they account up to 75 percent of gastric polyps in the geographic areas where H. pylori is common. They may be single or multiple in numbers. They can present in variable shapes and sizes. Typically they are small, dome-shaped, or stalked polyps with an average size of 10mm.They primarily occur in the antrum, but may develop in the fundus or cardia
Pathogenesis: The pathogenesis of hyperplastic polyps is related to unchecked, hyper-regenerative epithelium in response to an underlying chronic inflammatory stimulus.
Pathology: Microscopically, they are composed of elongated, dilated, and/or cystic, architecturally distorted, foveolar epithelium within an edematous stroma rich in vasculature. They may have varying degrees of chronic and active inflammation. Surface erosions and ulcerations are common in large polyps.
Clinical Presentation: Hyperplastic polyps are generally observed in the setting of inflamed and often atrophic gastric mucosa such as chronic atrophic gastritis, pernicious anemia, and chronic antral gastritis. Most of the polyps are asymptomatic but rarely can present with gastrointestinal bleeding, iron deficiency anemia and rarely obstruction.
Risk of Malignancy: The reported incidence of malignant change within a hyperplastic polyp ranges from 0.5 to 7.1 percent. Malignancy develops through a dysplasia/carcinoma sequence. The risk of malignancy in hyperplastic polyps is greater in polyps, which are more than 2 cm in size and pedunculated in shape.
Management: Removal of the underlying injury will cause regression of the hyperplastic polyps in up to 70%. Since hyperplastic polyps are associated with atrophic gastritis and H. pylori infection, the normal appearing antral and corpus mucosa should be sampled to assess the stage of gastritis and, thus the risk of cancer. Large hyperplastic polyps especially those which are more than 2cms in size should be resected completely. A subtotal gastrectomy may be considered when dysplasia or carcinoma is present beyond the confines of the polyp.
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2. Goddard AF, Badreldin R et al. The management of gastric polyps. Gut. 2010 Sep; 59(9): 1270-6. Epub 2010 Jul 30.
3. Park do Y, Lauwers GY. Gastric polyps: classification and management. Arch Pathol Lab Med. 2008 Apr; 132(4): 633-40.
Madhusudhan Sunkavalli, MD, University at Buffalo, Buffalo, NY
Bo Xu, MD, PhD, Roswell Park Cancer Institute, Buffalo, NY
Andrew J. Bain, MD, University at Buffalo, Buffalo, NY, Roswell Park Cancer Institute, Buffalo, NY