Endoscopic Removal of a Giant Complicated Hyperplastic Gastric Polyp

Abstract

The patient, a 40-year-old male, was referred to our clinic with intermittent nausea, vomiting and symptomatic anemia for 4 months. Notable hematological indices were low hemoglobin levels of 9.6 g/dl and hematocrit levels of 35.8%, while after receiving two units of concentrated red blood cells, at discharge; they achieved levels of 15.2 g/dl and 42.3%, respectively. Esophagogastroduodenoscopy revealed a 3 cm antral pedunculated polyp, prolapsing into pylorus thus causing intermittent pyloric obstruction and anemia. Histological examination revealed a hyperplastic polyp without evidences of malignancy. No atrophy, metaplasia, dysplastic changes or Helicobacter pylori infection were detected in samples taken from the antrum and the corpus; however, the examination provided evidence for gastritis. Follow-up endoscopy was provided after 12 weeks to see polypectomy site after a course of Pantoprazole administration, and to define symptom-free time after polypectomy. Endoscopic removal of complicated gastric polyps should be considered at the time of initial diagnostic endoscopy. Endoscopic resection of polyps enables to determine the exact histopathologic type as well as to effectively treat symptomatic gastric outlet obstruction and anemia.

Dear Sir,

Hyperplastic polyps represent the most common type of gastric polyps [1]. They are characterised by proliferation of foveolar cells with variable amounts of edematous stroma [1]. When hyperplastic gastric polyps occur in the antrum, they may prolapse into the pyloric channel, consequently causing gastric outlet obstruction and chronic blood loss leading to iron deficiency anaemia [2].

The patient, a 40-year-old male, was referred to our clinic with intermittent nausea, vomiting and symptomatic anaemia for four months. Notable haematological indices were low haemoglobin levels of 9.6 g/dl and hematocrit levels of 35.8%, while after receiving two units of concentrated red blood cells, at discharge; they achieved levels of 15.2 g/dl and 42.3%, respectively. Esophagogastroduodenoscopy revealed a 3 cm antral pedunculated polyp, prolapsing into pylorus thus causing intermittent pyloric obstruction and anaemia. Submucosal injection of the saline-epinephrine solution [3] in the basis of pedunculus and endo-loop placement was performed before the polyp was removed (Fig. 1). Rapid urease test for Helicobacter pylori performed on endoscopically taken tissue samples resulted negative. Histological examination revealed a hyperplastic polyp without evidence of malignancy. No atrophy, metaplasia, dysplastic changes or Helicobacter pylori infection were detected in samples taken from the antrum and the corpus; however, the examination provided evidence for gastritis. Histologically, hyperplastic polyp had corkscrew appearance characterised by marked elongation of the pits with branching and cystic dilatation of foveolae (Fig. 2A, 2B).

Figure 1.

Gastric polyp after removal

Figure 2.

A) Irregular and dilated mucosal foveolae, lined by columnar epithelial cells are set in inflamed lamina propria (A), Hematoxylin and Eosin stain, 5x magnification). B) Smooth muscle fascicles traverse between the dilated glands, similar to what is observed in Peutz-Jeghers polyp (B), Hematoxylin and Eosin stain, 10x magnification)

Follow-up endoscopy was provided after 12 weeks to see polypectomy site after a course of Pantoprazole administration, and to define symptom-free time after polypectomy.

Although most of these polyps are small (< 20 mm), large polyps may be encountered at endoscopy. The risk for complications is higher if the polyps exceed 20 mm in size [1]. Gencosmanoglu R. et al. [4] reported a similar case of a patient, in whom esophagogastroduodenoscopy revealed a prepyloric polyp causing intermittent gastric obstruction. Up to 80% of hyperplastic gastric polyps have been found to regress after eradication of H. pylori before endoscopic removal [5].

Endoscopic removal of complicated gastric polyps should be considered at the time of initial diagnostic endoscopy. Endoscopic resection of polyps enables to determine the exact histopathologic type as well as to effectively treat symptomatic gastric outlet obstruction and anaemia.

Ethics Committee Approval

The study protocol was approved by a local ethical committee of University Clinical Center of Kosovo.

Informed Consent

The participant gave written informed consent.