Git j club gastric polyps.

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Git j club gastric polyps.

  1. 1. CLINICAL GASTROENTEROLOGY& HEPATOLOGY 2013;11:1374–1384 Supervisor: Dr.Mohamed AlShekhani Management of Gastric Polyps: An Endoscopy-Based Approach Kurdistan Board gastroenterology weekly Journal club.
  2. 2. Gastric polyps: the 3 main types. FGPs HPPs ADPs
  3. 3. An abnormal growth of tissue projecting from the gastric mucosal membrane.
  4. 4. Fundal gland polyps: Now the most frequent in West BZ of wide PPIs Use Hyperplastic polyps: the 2nd most common polyps notable for their association with gastritis& their low but important potential for harboring dysplastic or neoplastic foci Adenomas: now raised intraepithelial neoplasia ,decreasing in parallel with HP; important as harbingers of GC, sp in E Asia. GIST have low incidence, no known associations, malignant potential is high; early diagnosis&proper management are crucial.
  5. 5. Inflammatory fibroid polyps: Should be recognized, particularly by pathologists, to avoid misdiagnosis. Gastric neuroendocrine tumors (carcinoids) important because of their association with either atrophic gastritis or MEN syndromes; those do not arise in these backgrounds have high malignant Potential & require aggressive management.
  6. 6. Polyps that reveal a malignancy upon histopathologic exam lose their polyp status, irrespective of their initial endoscopic appearance. Lesions (eg, lipomas, heterotopias, leiomyomas) are unlikely to cause clinical dilemmas.
  7. 7. Fundic gland polyps: The most common type of polyps detected at EGD in West. 6% of EGDs 74% of all gastric polyps submitted for HP. Endoscopically, usually multiple, small (1 cm), smooth, glassy, sessile. By NBI a honeycomb appearance with dense vasculature(nonspecific also seen in hyperplastic polyps).
  8. 8. Fundic gland polyps: Histology consist of one or more dilated oxyntic glands, lined by flattened parietal&mucous cells . Among the most characteristic lesions of the stomach. Regenerative appearance may be misinterpreted as dysplasia. True dysplasia, particularly high grade, is exceedingly rare and is virtually limited to fundic gland polyps found in patients with polyposis syndromes.
  9. 9. Fundic gland polyps: clinical approach 1 or more should undergo biopsy. Large polyps (1 cm) ,ulcerated, > 20, unusual location as antrum should prompt a more aggressive approach. Biopsy is not adequate because may not include dysplasia or neoplasia. When found in a young , esp if numerous (eg, 20),possibility of polyposis should be considered. Individuals with FAP typically are <40, occasionally have polyps in the antrum. When gastric polyps are associated with duodenal adenomas a familial polyposis syndrome strongly should be considered &colonoscopy recommended.
  10. 10. Fundic gland polyps: clinical approach If FGPs > 20 or > 1 cm & on PPI. Withdraw PPI & see if number or size reduced. If so & still need for PP,give I MINIMAL effective dose or change to another PPI or H2RBs. Measure serum gastrin. Exclude gastrinoma.
  11. 11. Hyperplastic Polyps Inflammatory proliferations of gastric foveolar cells (mucinproducing epithelial cells lining gastric surface& pits). inflammatory polyps or foveolar. Occur in patients with post-Billroth I & II gastric stumps exposed to bile. The classic association with mucosal atrophy, whether H pylorior autoimmune-induced. Now more with normal mucosa without HP.
  12. 12. Hyperplastic Polyps Equally common in men & women typically occur in the sixth&seventh decades ( 66 y). Endoscopically, most frequently in antrum,often multiple. Usually smooth, dome-shaped, 0.5-1.5 cm, may be larger. Large hyperplastic polyps often become lobulated, Pedunculated, surface typically is eroded result in chronic blood loss & IDA, Rarely, if large GOO. The overall prevalence of carcinoma in hyperplastic polyps is <2%, > ]in polyps >2 cm.
  13. 13. Hyperplastic Polyps >1 cm should be excised completely. If dysplasia or intramucosal carcinoma is found, but the stalk is not affected, the lesion considered completely cured. Excision accompanied by additional sampling of the unaffected mucosa from the antrum&corpusto to obtain reliable information about the topography/severity of the background gastritis & atrophy. When hyperplastic polyps arise in a background of chronic atrophic gastritis (a precursor lesion for gastric adenocarcinoma) the severity and extent of the atrophic gastritis should be evaluated, using the Operative Link for Gastritis Assessment (OLGA) or the Operative Link on Gastritis/Intestinal Metaplasia Assessment staging systems. Preferably 7-biopsy , 3 specimens from the antrum (which can be submitted in a single formalin container), 2 from the lesser curvature, 2 from the greater curvature, with each set in a separate container.
  14. 14. Hyperplastic Polyps If present, H pylori should be eradicated &endoscopic follow-up evaluation should be scheduled between 3 & 6 months after therapy to confirm successful eradication. Alternatively, noninvasive test as the urea breath test used. Patients with OLGA stages III and IV (moderate diffuse atrophy or severe atrophy in either the corpus or antrum, usually accompanied by extensive intestinal metaplasia) should be considered for longterm endoscopic surveillance.
  15. 15. Hyperplastic Polyps If present, H pylori should be eradicated &endoscopic follow-up evaluation should be scheduled between 3 and 6 months after therapy to confirm successful eradication. Alternatively, noninvasive test as the urea breath test used. Patients with OLGA stages III and IV (moderate diffuse atrophy or severe atrophy in either the corpus or antrum, usually accompanied by extensive intestinal metaplasia) should be considered for longterm endoscopic surveillance.
  16. 16. Gastric Adenomas (Raised Intraepithelial Neoplasia) The most common gastric neoplastic polyp is an epithelial (raised intraepithelial neoplasia) by the World Health Organization. H pylori–related sporadic gastric adenomas have become rare, accounting for <1% of all gastric polyps. This contrasts markedly with some East Asian regions, where the incidence of gastric cancer remains high &gastric adenomas still constitute approximately a quarter of all gastric polyps. similar frequency in men &women Most commonly velvety lobulated appearance ,usually solitary Can be found anywhere in the stomach, located more often in the antrum.
  17. 17. Gastric Adenomas (Raised Intraepithelial Neoplasia) Often arise in a background of atrophy & intestinal metaplasia typically associated with H pylori infection. As in the colon,gastric adenomas can be viewed as part of a sequence leading from dysplasia to carcinoma. The larger an adenomatous polyp, the greater the probability it contains foci of adenocarcinoma. Synchronous adenocarcinomas, reported in up to 30% of patients with adenomas ontaining foci of adenocarcinoma.
  18. 18. Gastric Adenomas (Raised Intraepithelial Neoplasia) Completely excisice all adenomas Severity/ extent of the atrophic gastritis should be evaluated. The same biopsy protocols&use of the OLGA or Operative Link on Gastritis/Intestinal Metaplasia all patients with a diagnosis of gastric adenoma need to be placed in a surveillance program irrespective of their atrophy stage. Eradication of H pylori followed by confirmation of the cure by biopsy examination or urea breath test is necessary. Gastric adenomas are neoplastic with malignant potential, so multiple sections from each lesion must be examined to exclude invasion. Outside the research arena, neither special stains nor molecular studies are necessary.
  19. 19. (A) Flat gastric adenoma with a velvety appearance in the distal body of the stomach. (B) Gastric adenomas consist of dysplastic columnar epithelium indistinguishable from colonic adenoma. In resected specimens, the only clue to their gastric origin is often a small remnant of gastric tissue from which they originate (arrow).
  20. 20. Gastrointestinal Stromal Tumors Neoplastic proliferations of the interstitial cells of Cajal (or their precursors) Arise in any segment of GIT rarely, abd/ pelvic cavity. 4000 new cases/year in US 40-60% in stomach, 2% of all gastric tums. >in men >in the gastric fundus. Can be found in other regions of the stomach. No predisposing factors the gastric mucosa overlying these tumors may be
  21. 21. Gastrointestinal Stromal Tumors Endoscopically, GISTs are wellcircumscribed submucosal lesions; the overlying gastric mucosa is usually normal, but it may have an eroded or ulcerated center Biopsy often normal so the best way is to perform an EUS -FNA or a tru-cut needle biopsy. Composed by dense aggregates of fusiform cells (spindle cells) Two main types in the stomach (spindled & epithelioid) with subtypes. (presence of perinuclear vacuoles, numbers of mitoses, necrosis& tissue invasion) help predict their behavior.
  22. 22. The vast majority: <1 cm Asymptomatic detected incidentally during an endoscopic Exam for other indications. As they grow, they cause erosions or ulcerations or compress adjacent structures; The 2 more common manifestations are bleeding (occult or overt)& pain. GIST: Clinical approach
  23. 23. All must be considered as having malignant potential: Up to 50% larger GISTs (2 cm) have metastatic disease at presentation, usually to the liver. A good correlation between size, mitotic activity&clinical behavior. Surgical resection recommended if >2cm; ? Endoscopic enucleation followed by surveillance is an option for smaller. TKIs in cases of metastasis& surgically unresectable or neoadjuvant after surgery. GIST: Clinical approach
  24. 24. IHC: The antibody CD117, stains 95% the remaining 5% ( typically more epithelioid) stain with antibodies to DOG-1 or platelet-derived growth factor . If none of these 3 stains, tumors of smooth muscle (leiomyomas) or neural (neuromas, schwannomas) origin should be Considered &immunostaining for actin& S-100 should be performed. GIST: Clinical approach
  25. 25. Inflammatory fibroid polyps: Vanek tumors What’s Your Message?
  26. 26. Extremely rare < 0.1% of all gastric polyps. Endoscopy: firm, solitary, sessile or pedunculated,often ulcerated. The histology distinctive: submucosal proliferations of spindle cells, small vessels& conspicuous inflam infiltrate with a predominance of eosinophils. IHC staining suggests these polyps have a dendritic cell origin. A recent study:70% of inflam fibroid polyps contain gain-of-function mutations in the platelet-derived growth factor Receptor polypeptide gene, similar to those found in CD117-negative GISTs, suggesting a neoplastic Process.
  27. 27. Clin approach: Most are asymptomatic. Larger polyps cause abd pain, early satiety, anemia, GOO, The EUS appearance may be helpful in establishing the diagnosis, characterized by an indistinct margin, a hypoechoic homogeneous lesion, within 2nd or 3rd layer with an intact 4th layer. Extremely rare, once familiar with their unique morphology they can be diagnosed instantly. IHC: stain for CD31.
  28. 28. Gastric NETs (carcinoid): < 2% of gastric polyps. Of 3 types: Type I , 70- 80% of all gastric NETs. They are associated with hypergastrinemia resulting from autoimmune (corpus-restricted) atrophic gastritis found more commonly in elderly, sp women, with atrophic gastritis and often are associated with pernicious anemia. These tumors are small (1 cm), confined to the oxyntic mucosa, tend to be multiple, usually co-exist with multifocal ECL cell hyperplasia. Gastric NET tend to be found incidentally, often in patients undergoing EGD as part of an evaluation for anemia.
  29. 29. Gastric NETs (carcinoid): Type II gastric NET are associated with hypergastrinemia resulting from a gastrin-secreting tumor. They frequently are detected as part of the work-up for MEN-1 syndrome or for Zollinger–Ellison syndrome. Are usually small (1 cm). This type is the most uncommon only 5-8% of gastric NET.
  30. 30. Gastric NETs (carcinoid):Clin approach Type I and II tumors often can be removed endoscopically. In select patient with numerous&recurrent type I NETs, antral resection could be a reasonable option. Newer treatments; gastrin receptor antagonist netazepide being investigated. Sporadic carcinoids (type III) may present with anemia, epigastric pain, or signs and symptoms caused by metastases, including the rare carcinoid syndrome (characterized by cutaneous flushing, diarrhea, bronchospasm, and cardiac valvular lesions). Surgery followed with chemotherapy is the treatment of choice.
  31. 31. Gastric NETs (carcinoid):IHC Neuroendocrine tumors are best diagnosed withIHC stain (synaptophysin, chromogranin A, or CD56). These 3 stains are essentially equivalent to highlight neuroendocrine markers: In addition, a Ki-67 stain should be performed to count the percentage of proliferating cells &the grade of the tumor.
  32. 32. Overall approach: After the histopathologic diagnosis is received, a decision whether polypectomy is needed ;endoscopic or surgical. Several factors should be considered when making that decision: 1. Risk of missing more serious pathology in the large polyps. 2. The presence of symptoms 3. The patient’s overall health status preferences 4. local expertise. Biopsy-first approach is reasonable because it allows definitive treatment to be planned according to pathology results& after consultation with the patient. If resection is planned, the endoscopist should be prepared to deal with potential complications as many are highly vascular & bleed; some (inflammatory fibroid polyps, carcinoids,GISTs) have submucosal components that increase the risk of perforation.
  33. 33. Overall approach: After removed or sampled, the non-affected gastric mucosa should be inspected& a minimum of 3 biopsy specimens from the antrum (including one from the incisura angularis)& 2 - 4 from the corpus, both the greater & lesser curvature, should be submitted for pathologic exam, ideally in separate containers, to see if there is H pylori infection, atrophic gastritis, possibly with diffuse neuroendocrine hyperplasia, or a normal mucosa. Each of these findings would point to different management.
  34. 34. Follow-up evaluation: No evidence-based guidelines exist. A surveillance endoscopy on non-fundic gland polyps within 1 year is a reasonable approach to evaluate the site for recurrence & assess for new polyps. Follow-up evaluation after resection of polyps with high-grade dysplasia or early cancer should be individualized, but (at least for the first 2–3 years) short intervals (eg, 6 mo) would seem Desirable. Gastric carcinoids managed endoscopically (usually type 1) should be followed up with endoscopy every 1 to 2 years.
  35. 35. SCQ1: The most common gastric polyp in the west is: A.Fundic gland polyps. B.Hperplastic polyps. C.Raised intraepithelial neoplasia. D.Inflammatory fibroid polyps. E.NET.
  36. 36. SCQ1: The most common gastric polyp in the west is: A.Fundic gland polyps. B.Hperplastic polyps. C.Raised intraepithelial neoplasia. D.Inflammatory fibroid polyps. E.NET.
  37. 37. SCQ2: The gastric polyp that respond to a therapeutic trial is: A.Fundic gland polyps. B.Hperplastic polyps. C.Raised intraepithelial neoplasia. D.Inflammatory fibroid polyps. E.NET.
  38. 38. SCQ2: The gastric polyp that respond to a therapeutic trial is: A.Fundic gland polyps. B.Hperplastic polyps. C.Raised intraepithelial neoplasia. D.Inflammatory fibroid polyps. E.NET.
  39. 39. SCQ3: Fundic gland polyps in the west is the most common type BZ of: A. Decreased incidence of HP infections. B. Decreased incidence of hyperplastic polyps. C. Increased survival of FAP patients. D.Widespread use of antibiotics use. E. Widespread use of PPI use.
  40. 40. SCQ3: Fundic gland polyps in the west is the most common type BZ of: A. Decreased incidence of HP infections. B. Decreased incidence of hyperplastic polyps. C. Increased survival of FAP patients. D.Widespread use of antibiotics use. E. Widespread use of PPI use.
  41. 41. SCQ4: The rarest type of gastric polyps is: A. FGPs. B. HPPs. C. RIN. D.IFPs. E. NET.
  42. 42. SCQ4: The rarest type of gastric polyps is: A. FGPs. B. HPPs. C. RIN. D.IFPs. E. NET.
  43. 43. SCQ5: IFP is usually diagnosed on: A. OGD. B. Barium meal study. C. Histopathology. D.EUS. E. PET scan.
  44. 44. SCQ5: IFP is usually diagnosed on: A. OGD. B. Barium meal study. C. Histopathology. D.EUS. E. PET scan.
  45. 45. SCQ6: IFP has a characteristic appearance on: A. OGD. B. EUS. C. Barium. D.CT. E. PET scan.
  46. 46. SCQ6: IFP has a characteristic appearance on: A. OGD. B. EUS. C. Barium. D.CT. E. PET scan.
  47. 47. SCQ7: The finding of FGPs & ampullary polyp should indicate: A. OGD. B. EUS. C. Barium. D.CT. E. Colonoscopy.
  48. 48. SCQ7: The finding of FGPs & ampullary polyp should indicate: A. OGD. B. EUS. C. Barium. D.CT. E. Colonoscopy.
  49. 49. SCQ8: The finding of numerous, large or irregular shaped FGPs should raise the possibility of: A. FAP. B. HNPCC. C. PJS. D.JPS. E. NETs.
  50. 50. SCQ8: The finding of numerous, large or irregular shaped FGPs should raise the possibility of: A. FAP. B. HNPCC. C. PJS. D.JPS. E. NETs.
  51. 51. SCQ9: The following gastric polyps are associated with gastric atrophy except: A. FGP. B. HPP. C. RIN. D.IFP. E. NETs.
  52. 52. SCQ9: The following gastric polyps are associated with gastric atrophy except: A. FGP. B. HPP. C. RIN. D.IFP. E. NETs.
  53. 53. SCQ10: The MOST common gastric NET is: A. Type 1. B. Type 2. C. Type 3. D. All Equal. E. None .
  54. 54. SCQ10: The MOST common gastric NET is: A. Type 1. B. Type 2. C. Type 3. D. All Equal. E. None .
  55. 55. SCQ11: The NET with worst prognosis is: A. Type 1. B. Type 2. C. Type 3 sporadic . D. All Equal. E. None.
  56. 56. SCQ12: The NET with worst prognosis is: A. Type 1. B. Type 2. C. Type 3 sporadic . D. All Equal. E. None.
  57. 57. SCQ13: The NET type that can respond to netazepide include: A. Type 1. B. Type 2. C. Type 3 sporadic . D. A&B. E. None.
  58. 58. SCQ13: The NET type that can respond to netazepide include: A. Type 1. B. Type 2. C. Type 3 sporadic . D. A&B. E. None.
  59. 59. SCQ14: The gastric GIST that doesn't’t stain with the usual GIST –specific stains should raise the possibility of all except: A. Leimymoma. B. Neuroma. C. Shwanoma. D. Epiotheloid type. E. EGC.
  60. 60. SCQ14: The gastric GIST that doesn't’t stain with the usual GIST–specific stains should raise the possibility of all except: A. Leimymoma. B. Neuroma. C. Shwanoma. D. Epitheloid type. E.None.
  61. 61. SCQ15: The best diagnostic approach to gastric GIST is: A. EUS-FNA. B.EUS- Truecut needle biopsy. C. OGD biopsy. D. None. E.All.
  62. 62. SCQ15: The best diagnostic approach to gastric GIST is: A. EUS-FNA. B.EUS- Truecut needle biopsy. C. OGD biopsy. D. None. E.All.

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