Gastric polyps: a retrospective cohort analysis of 23,668 endoscopies indicates changing epidemiological and phenotypic characteristics

Introduction

Growing adoption of endoscopic procedures in clinical practice has gradually increase the detection rate of gastric polypoid lesions.

Aim

To identify the epidemiologic characteristics of gastric polyps as well as changes of these parameters during a 15-year period.

Material and methods

We reviewed all the upper endoscopies archived in our database reporting a polypoid lesion from 2003 to 2018. Demographic data, indication for endoscopy, morphological characteristics of polyps, histology, and presence of Helicobacter pylori were collected. We compared the abovementioned data between 2 periods: 2003-2010 and 2010-2018.

Results

A total of 989 (4.2%) patients from 23,668 reviewed were identified to harbour a polypoid lesion. Mean patient age was 63.2 years, with 58.8% being female. Most polyps (65.2%) were less than 5 mm in diameter and located in the fundus. Hyperplastic polyps (HPs) were the predominant type (28.6%) while fundic gland polyps (FGPs) were found in 24.1% of patients. Adenomas were the least common type (2.7%). Other pathology was identified in 43.3%. Comparison between the 2 periods revealed a rise of FGPs against HPs with a concomitant shift of location from antrum to fundus and an increase in the number of polyps per patient.

Conclusions

FGPs and HPs were the most common polyps found in our cohort, with a change of their pattern during the 15 years. It is imperative to acknowledge the distinct characteristics of gastric polyps so as to properly assess the malignant potential that some of them, or their surrounding gastric mucosa, harbour.

Giant hyperplastic gastric polyp: A diagnostic dilemma!!

Gastric hyperplastic polyps (GHP) account for a majority of benign gastric polyps. Most of the GHPs are <2 cm, asymptomatic, and incidentally detected on endoscopy or radiologically. With increasing size, these polyps manifest as upper gastrointestinal bleeding, iron deficiency anemia, and gastric outlet obstruction (GOO). We report an unusual case of giant GHP simulating gastric carcinoma and posing as a diagnostic challenge for the surgeons emphasizing the diagnostic role of histopathology. A 46-year-old female presented with clinical features of progressive GOO for 1 year. Endoscopy revealed an eccentric proliferative lesion in the antrum. Computed tomography showed a polypoidal, enhancing mural thickening involving distal body and antro-pyloric region measuring 8.4 cm × 6.6 cm × 1.8 cm. Subtotal gastrectomy was done in view of clinical features of GOO and having a clinical suspicion of malignancy. Gross examination showed a giant sessile hyperplastic polyp with lobulated surface. Microscopy revealed features of a large, sessile hyperplastic polyp without any evidence of dysplasia. The patient was symptomatically relieved and is on follow-up. To conclude, giant GHPs can mimic gastric carcinoma on endoscopy and radiology. The possibility of giant GHP should be kept in mind in the presence of an intensely contrast-enhancing polypoidal lesion in the gastric antrum. Long-term endoscopic follow-up is recommended.

Gastric Inflammatory Fibroid Polyp: A Rare Cause of Occult Upper Gastrointestinal Bleeding

Inflammatory fibroid polyps (IFPs) are rare mesenchymal lesions that can arise throughout the gastrointestinal tract. These tumors represent less than 0.1% of all gastric polypoid lesions and are frequently found incidentally on endoscopic evaluation. While presenting symptoms depend on the location of the tumor, gastric polyps commonly present with epigastric pain and early satiety. We hereby delineate the case of a middle-aged female who presented with chronic iron deficiency anemia and a positive fecal occult blood test. She underwent an upper endoscopy, which revealed an actively oozing umbilicated lesion in the gastric antrum. Endoscopic ultrasound divulged the submucosal origin of the lesion. It was subsequently excised using endoscopic mucosal resection. Pathologic examination of the resected specimen confirmed the diagnosis of gastric IFP. Furthermore, we conducted a systematic literature search of the MEDLINE database centered on gastric IFPs from January 2000 till March 2020. The data on patient demographics, clinical features, endoscopic findings, lesion site and size, and treatment approaches were collected and analyzed. This article illustrates the overarching need for clinicians to be vigilant of gastric IFPs presenting with initial clinical symptoms suggestive of occult upper gastrointestinal bleeding. Prompt diagnosis and management of gastric IFPs carry paramount importance to combat chronic unexplained iron deficiency anemia following occult bleeding in such patients. A concoction of endoscopy, biopsy, and immunohistochemical examination can be employed toward their prompt detection. Although gastric IFPs have conventionally been treated with surgery, endoscopic resection is now emerging as a safe and efficient therapeutic modality.

Gastric Hyperplastic Polyps after Argon Plasma Coagulation for Gastric Antral Vascular Ectasia in Patients with Liver Cirrhosis: A Case Suggesting the "Gastrin Link Theory"

We herein report a case of gastric hyperplastic polyps after argon plasma coagulation (APC) for gastric antral vascular ectasia (GAVE) in the antrum of a 65-year-old man with liver cirrhosis and hypergastrinemia induced by long-term proton pump inhibitor (PPI) use. Two years after APC therapy, endoscopy demonstrated multiple gastric polyps in the antrum and angle. A gastric polyp biopsy indicated foveolar epithelium hyperplasia, which was diagnosed as gastric hyperplastic polyps. One year after switching to an H2 blocker antagonist, endoscopy revealed that the polyps and GAVE had disappeared, with normal gastrin levels suggesting that PPI-induced hypergastrinemia had caused gastric hyperplastic polyps after APC therapy, and the polyps had disappeared after discontinuing PPIs.

The pathology of gastric and duodenal polyps: current concepts

The liberal use of upper endoscopy has led to an increased detection of gastric and duodenal polyps, which are identified in as many as 6 and 4.6% of patient examinations, respectively. Gastroduodenal polyps are a heterogeneous group of lesions that can be neoplastic or non-neoplastic (e.g. hyperplastic or heterotopical). Most polyps present characteristic topographical features, as well as endoscopic appearance and size. Evaluation of the surrounding mucosa is essential in assessing the underlying pathology (e.g. Helicobacter pylori, autoimmune gastritis or inherited polyposis syndromes). Phylogenetically, gastric and duodenal polyps can be classified according to the epithelial compartment from which they derive. Polyps that arise from the surface epithelium can either be of foveolar or intestinal type, and they can develop from either the native mucosa or the metaplastic epithelium (gastric intestinal metaplasia or duodenal foveolar metaplasia). Other polyps develop from the deeper glandular component, such as pyloric/oxyntic gland derived subtypes. In this review we focus upon epithelial polyps, with an emphasis on the most common and clinically relevant lesions, and present recently described entities.

Impact of endoscopic sedation on gastric polyp detection: A one-center retrospective observational study

Sedation esophagogastroduodenoscopy (EGD) has become more prevalent in many countries. However, owing to the limitation of health insurance payment for sedation EGD in Taiwan, non-sedation EGD still accounts for the majority of cases. This study was aimed to explore the differences between the sedation and non-sedation groups in terms of endoscopic findings, such as detection rate of gastric polyp of any size, number of detected gastric polyps, and location of the gastric polyps detected.We enrolled 10,940 patients who underwent EGD between January 1, 2016 and December 31, 2016 at the Tri-Service General Hospital; among the patients, 1900 received intravenous sedation (IVS) and 9040 did not. The data reviewed included demographics, parameters of the polyp (number, size, and location), and pathology.Compared with the non-sedation group, the sedation group had a higher overall polyp detection rate (P < .001); a greater number of detected polyps (Odds ratio 1.50, P = .007); and a higher detection rate of smaller polyps, such as fundic gland polyp, and hyperplastic polyp (P < .001). Among the pathological findings, gastric neuroendocrine tumor (NET) was detected using EGD in 2 cases and manifested as small polyps (<0.05 cm), and it showed significantly better detection rates in the sedation EGD group than in the non-sedation EGD group (P = .002).Sedation EGD could enhance a patients willingness and cooperation during EGD. Furthermore, sedation EGD increased the detection rates of small gastric polyps and was more likely to enable identification of unusual findings, such as gastric NET.

Patients with Gastric Polyps need Colonoscopy Screening at Younger Age: A Large Prospective Cross-Sectional Study in China

Background To date, it is not clarified whether patients with gastric polyps without any alarming symptoms for colorectal neoplasia need colonoscopy screening. The objective of this study is to prospectively determine the association between gastric polyps and colorectal neoplasia.

Methods A multicenter prospective cross-sectional study was performed from July 2012 to December 2014. We compared patients with and without gastric polyps for prevalence of colorectal adenomas. The odds ratios (OR) were computed by logistic regression analysis after multivariable adjustments.

Results Totally 1546 patients were included, with 770 patients in the gastric polyp group and 776 in the age- and sex- matched control group. Patients with gastric polyps had greater odds of having any colorectal adenoma (adjusted OR=2.34, 95% confidence interval [CI]: 1.79 to 3.06, p<0.001) and advanced colorectal adenomas (adjusted OR=2.71, 95% CI: 1.74 to 4.23, p<0.001) than those without. The positive association between gastric polyps and colorectal adenomas remained significant in both women (OR=2.34, 95% CI: 1.66 to 3.29, p<0.001) and men (OR=1.87, 95% CI: 1.31 to 2.66, p=0.001). Patients over the age of 40 with gastric polyps had a higher prevalence of colorectal adenomas than those without (40-49yr: OR=1.81, 95% CI=1.02-3.21, p=0.04; 50-59yr: OR=1.88, 95% CI=1.26-2.81, p<0.001; 60-74yr: OR=2.62, 95% CI=1.73-3.98, p<0.001).

Conclusions The presence of gastric polyps is significantly associated with a higher prevalence of colorectal adenomas, especially advanced colorectal adenomas. Colonoscopy might be considered in patients with gastric polyps, of any gender, and over the age of 40.

Type 1 Gastric Neuroendocrine Tumor Found on Endoscopic Polypectomy

Gastric neuroendocrine tumors (GNET) are rare gastric neoplasms accounting for <1% of all gastric neoplasms. The World Health Organization (WHO) categorized these neoplasms as types 1-3 to help predict malignant potential and long-term survival and guide management. Improved outcomes have been shown with endoscopic resections, but further studies are needed to confirm the best approach. We present a case of a 56-year-old woman who demonstrated the classic features of type one GNET with mucosal and submucosal involvement in the setting of primary atrophic gastritis, secondary hypergastrinemia, and underlying pernicious anemia. In general, standardizing treatment has been difficult due to a variable presentation.

Hyperplastic gastric polyp with foci of ossification

Stromal ossification has been reported in relation with gastrointestinal (GI) cancers. Heterotopic ossification of benign gastric polyps with bone formation is rarely documented and sometimes associated with calcification. Thus, the presence of foci of metaplastic bone (FMB) does not always imply GI cancer.

Evaluation of patients with gastric polyps

OBJECTIVE:

The incidence of gastric polyps (GPs) greatly differs according to study populations and was found to be 0.33%–6.7% in various studies. The majority of GPs are composed of hyperplastic polyps (HPs), fundic gland polyps (FGPs), and adenomatous polyps (APs). Although APs have a high risk of malignant potential, sporadic FGPs have no malignant potential. Conversely, HPs have a low risk of malignant potential. It is not sufficient to perform a biopsy to identify the polyp type and the presence of dysplasia; thus, some polyps may require multiple biopsies or total excision.

METHODS:

This retrospective study included patients with GPs or polypoid lesions found on esophagogastroscopy with polyp or malignant histology on biopsy at Ankara Numune Training and Research Hospital Endoscopy Unit between 2005 and 2011.

RESULTS:

In a series of 56.300 upper endoscopies, 192 patients (0.34%) were found to have GPs. Among the patients, 51 (26.6%) were men and 151 (73.4%) were women. The average age of the patients was 61.9±13.3 (14–90) years. The frequency of HPs, APs, and FGPs were 88%, 2.6%, and 1.6%, respectively. The size of the polyps was ≤1 cm in 137 (70%) patients. One polyp was determined in 141 (73.4%) patients. The most common localizations of polyps were the antrum and corpus. Endoscopic snare polypectomy was performed in 64 patients. One bleeding episode was observed, which required endoscopic treatment after ESP.

CONCLUSION:

In our study, the GP frequency was low (0.34%), whereas the frequency of HP maybe high due to the high frequency of Helicobacter pylori (HPy) infection in our country. The frequency of FGP is probably low due to the high frequency of HPy infection and the short-term use of proton-pump inhibitors.

Inflammatory fibroid polyp of the gastric antrum presenting as hypovolemic shock: Case report and literature review

Inflammatory fibroid polyps (IFP) are an extremely rare entity that arise within the submucosa of the gastrointestinal tract, and represent less than 0.1% of all gastric polyps. They are most commonly localized to the gastric antrum, small intestines and recto-sigmoid colon. IFPs are most commonly found incidentally upon endoscopic evaluation in the absence of symptoms. Presenting symptoms depend on the location of the tumor, although polyps located in the stomach most commonly present with epigastric pain and early satiety. Classic histologic features include perivascular onion skinning of spindle cells with an abundance of eosinophilic infiltration. The prompt diagnosis and management of IFP is essential due to its underlying risk for intussusception, outlet obstruction and acute hemorrhage. In addition, recent evidence has shown that IFP is driven by an activating mutation in the platelet derived growth factor receptor alpha (PDGFRA) gene, suggesting a neoplastic etiology. Herein, we discuss a case of a 65-year-old woman with an inflammatory fibroid polyp of the gastric antrum who initially presented with early hypovolemic shock and melena. Diagnosis was made by endoscopic visualization, biopsy and immunohistochemical analysis.

Fundic Gland Polyposis Associated with Proton-Pump Inhibitor Use

We describe the case of a man with fundic gland polyposis associated with proton-pump inhibitor (PPI) use. Some investigators have reported an association between long-term PPI use and an increase in the risk of developing fundic gland polyps (FGPs). These FGPs are considered to be reversible on stopping PPI treatment. The current patient had used a PPI for 10 years, resulting in multiple FGPs in his gastric body. However, 6 months after cessation of the PPI, the FGPs had obvously regressed, even though a histamine-2 receptor antagonist had subsequently been prescribed. This case demonstrates a link between PPI treatment and FGPs.

LEARNING POINTS

Long-term proton-pump inhibitor (PPI) use can increase the risk of developing fundic gland polyps (FGPs).This phenomenon is thought to be reversible, and a few case reports have demonstrated spontaneous resolution of FGPs after cessation of PPI use.When fundic gland polyposis is detected, a family history of polyposis and a history of PPI use should both be sought.

Chief cell-predominant gastric polyps: a series of 12 cases with literature review

AIMS

Rare gastric lesions composed of a combined proliferation of chief and oxyntic cells have been variably called adenocarcinoma of fundic gland type and oxyntic gland polyp/adenoma. Herein, we present a series of cases that show a morphological spectrum of chief and oxyntic cell proliferations.

METHODS AND RESULTS

Routine and consultation cases were collated from five institutions. Information regarding site, size, endoscopic appearance, clinical history and medication use, when available, was accrued, as was the histological features and immunoprofiles. A total of 12 cases were collated. Age ranged from 39 to 81 years. All the lesions were located in the fundus; seven of eight were polypoid lesions endoscopically. Lesions were primarily solitary, averaged 4.6 mm in diameter (largest 9 mm) and comprised >50% chief cells. The predominant architectural pattern was of anastomosing and solid and clustered glands or a mixture of these patterns. Lesions were limited mainly to the mucosa, although two showed submucosal involvement. None had known metastatic disease.

CONCLUSIONS

This series included lesions that were previously described as gastric adenocarcinoma of fundic gland type and oxyntic gland polyp/adenoma. They are located exclusively in the fundus and composed predominantly of chief cells with low-grade cytology and appear to show a morphological continuum.

A prospective study of atrophic gastritis and stomach cancer risk

The relation of atrophic gastritis, other gastric lesions and lifestyle factors to stomach cancer risk was prospectively studied among 3,914 subjects who underwent gastroscopic examination and responded to a questionnaire survey at the Aichi Cancer Center Hospital. During 4.4 years of follow-up on average, 45 incident cases of stomach cancer were identified at least three months after the initial examination. If the baseline endoscopic findings indicated the presence of atrophic gastritis, the risk of developing stomach cancer was increased 5.73-fold, compared with no indication at the baseline. The risk further increased with advancing degree of atrophy and increasing extension of atrophy on the lesser curvature. These trends in the relative risks were statistically significant (P = 0.027 and P = 0.041, respectively). The risk of developing stomach cancer was statistically significantly increased among subjects with gastric polyps, but not among those with gastric ulcer. Stomach cancer cases tended to consume more cigarettes, alcohol, rice, pickles and salted fish gut/cod roe and less fruits and vegetables and to have more family histories of stomach cancer than noncases, although these differences were not statistically significant. The results of the present study provide additional evidence on the relation between atrophic gastritis and stomach cancer and suggest a need for intensive follow-up of patients with atrophic gastritis and gastric polyps.

Endoscopic Nd-YAG laser therapy for gastric polyp

With the development of a special quartz fiberoptic transmission system, the application of laser energy through an endoscope became possible. Now, endoscopic laser therapy is widely used for gastrointestinal bleeding, and gastrointestinal neoplasm, and we have removed broad-based gastric polyps using an endoscopic Nd:YAG laser in 12 patients between January and December 1985. The size of the polyps ranged from 0.2 cm to 1.0 cm in diameter. The most frequent location for the polyp was in the antrum (7 cases) and followed by the fundus (5 cases). The application number of laser energy was from 6 to 58 and the small lesions of the 10 patients were completely ablated by the first endoscopic laser therapy. Follow-up endoscopy in all patients revealed no new polyp formation, but all patients had a residual ulcer at the end of the first week post polypectomy, and ulcers were healed by the fifth week of follow up.