Management of gastric polyps

Honorary Senior Clinical Lecturer, University of Sheffield
Consultant Gastroenterologist
Barnsley Hospital NHS Foundation Trust, UK
©1st Postgraduate course, SSG Feb 13 elmuhtady.said@nhs.net

Introduction
Epidemiology
Classification
General Management
Management of certain polyps
Summary and Recommendations
©1st Postgraduate course, SSG Feb 13, SAID EM

BSG Guidelines
Gut 2010:59:1270-1276.doi:10.1136

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Introduction
• Defined as luminal lesions projecting above
the plane of the mucosal surface.
• The main goal : to rule out the possibility of
malignancy.
• Various subtypes of gastric polyps are
recognized and generally divided into non-neoplastic
and neoplastic.
Arch Pathol ©1st Postgraduate course, SSG Feb 13, SAID EM Lab Med. 2008 Apr;132(4):633-40

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Epidemiology
• Few large epidemiological studies.
• Incidence: 1-3% of all gastroscopies.
• M=F.
• ⅔ above age of 60 years.
• Multiple in >25%.
• Usually asymptomatic, > 90% found incidentally.
• Large polyps can present with bleeding, anaemia
or abdominal pain.
Archimandrits A et ©1st Postgraduate course, SSG Feb 13, SAID EM al, Ital J Gastroentrol 1996;28:1524

Epidemiology
• Frequency and type of gastric polyps vary
depending on the population and location.
H Pylori common
PPI less common
H Pylori less common
PPI common
Hyperplastic/ adenoma> Fundic Fundic> Hyperplastic/ adenoma
• Fundic glands polyp common in the West.
• Specific genetic mutations are responsible for
polyp formation.

Classification
Different classifications:
Histology based
WHO (controversial)

BSG Classification
Benign epithelial gastric polyps BEGP Non-mucosal intramural polyps
Fundic gland polyps Gastrointestinal stromal tumours
Hyperplastic polyps Neuroendocrine tumours
Adenomatous polyps Fibroma and fibromyoma
Hamartomatous polyps Inflammatory fibroid polyps
Polyposis syndromes Ectopic pancreas
Lipoma, Leiomyoma
Neurogenic and vascular tumours

BENIGN EPITHELIAL GASTRIC POLYPS
BEGP

Sporadic Fundic gland polyps
Fundic Gland polyps
• Two types: sporadic or associated
with polyposis syndrome.
• Typically small (0.1 - 0.8 cm),
hyperemic, sessile, flat, nodular
lesions that have a smooth surface
contour .
• Exclusively in the gastric corpus.
can sometimes be large.
• Microscopically :Composed of
normal gastric corpus-type
epithelium, arranged in a
disorderly and/or microcystic
configuration.

Sporadic Fundic gland polyps
Fundic Gland polyps
• Sporadic FGP: F>M, middle age, 40% multiple.
• Long term PPI associate with 4x risk of FGP.
• H Pylori infection appears to protect the
development of FGP.
Jalving M et al,Aliment Pharmacol Ther 2006;24:1341

FGP in FAP
• Occur in 20-100 % of patients with FAP
• Early age (average 40)
• Mutation of the APC gene
• Usually multiple, carpet the body of stomach
• Epithilial dysplasia occur in 25-41% of FAP
associated polyposis

Hyperplastic polyps
• 75 % of gastric polyps in areas where
H. pylori is common.
• Small, dome-shaped, or stalked
polyps (average size 1.0 cm) ,single
or multiple.
• Primarily in the antrum, but may
develop in the fundus or cardia.
• Microscopically :elongated, dilated
or cystic, architecturally distorted,
foveolar epithelium within
chronically inflamed lamina propria.

Adenomatous polyps
• 6 to 10 % of gastric polyps.
• Found in the antrum, some occur in
the corpus and cardia.
• May be flat or polypoid.
• Range in size from a few mm to
several cm.
• Microscopically: similar to typical
colonic adenomas:tubular,
tubulovillous, or villous,are sessile
or stalked, occasionally large sizes.

Hamartomatous polyps
• Rare, Include:
1. Juvenile polyps:solitary, antral, inflammatoty or
hamartomatous, no malignant potential.
2. PJS: AD,hamartomatous GI polyps, mucocutan.
Pigmentaion , increase risk of cancer.
3. Cowden disease: AD, orocutaneous hamartomatous ,
extra GI abnormalties.
• Malignant transformation rare.

NON-MUCOSAL INTRAMURAL POLYPS

Inflammatory fibroid polyps
• Vanek tumours.
• Rare, 1% of all gastric polyps.
• Originate from submucosa, usually in
antrum or peripyloric area.
• Central depression/ ulceration.
• Asymptomatic, can be present with
bleeding or gastric outlet obstruction.
• No malignant potential but ass with
chronic atrophic gastritis.
• Microscopically :Submucosal
proliferation of spindle cells/small
vessels with an inflammatory infiltrate
with many eosinophils.

Gastric neuroendocrine tumour NETs
• Histologically, composed of
enterochromaffin-like cells.
• May be asymptomatic, PUD, abd
pain, bleeding or carcinoid syndrome.
• Type 1: 80%, sessile, ass with atrophic
gastritis, pernicious anaemia.
• Type 2: 5%, Zollinger-Ellison in the
setting of MEN1.
• Type 3: 15% , sporadic, malignant
potential.

Stromal tumour GISTs
• 1-3% of gastric tumours.
• M>F, typically in the fundus.
• Submucosal, mucosal Bx inadequate.
• EUS with FNA is best diagnosis.
• Malignancy: low to high based on
polyp size & level of mitotic activity.
• Histology: spindle cells in 70-80%,
epitheloid aspect in 20-30%.
• Immunohistochemistry:95% of all
GISTs are CD117-positive.

GENERAL MANAGEMENT

General principles
General management issues are
commonly applied to all patients
with gastric polyps.
Once a polyp is observed, it is
removed or biopsied and its
pathology identified
Prognosis and management are
specific to the underlying pathology.

Polyp Histology
Check for H.Pylori infection
Gastric mucosa histology
Multiple polyps
Relationship to colonic polyps
Surveillance
General principles

Polyp Histology
All gastric polyps should be biopsied and examined
microscopically for histologic characterization due to risk of cancer.
• Forceps biopsy alone cannot
exclude foci of HGD or early
gastric cancer in large (>1 cm)
polyps.
• Polypectomy is generally
indicated for all neoplastic
polyps and other polyps ≥1 cm
in diameter.

H.Pylori infection
All patients with hyperplastic gastric polyps should be tested
for H. pylori, if positive, treated with eradication therapy.
• Treatment has been associated
with regression of polyps in some
patients.
• Because the pathology is often
not known at the time of initial
endoscopy, we also biopsy the
normal appearing mucosa of
patients with gastric polyps for H.
pylori.

Gastric mucosa histology
Take biopsy of the normal mucosa
• Because hyperplastic polyps &
adenomatous polyps are often
associated with atrophic
gastritis→ the normal intervening
non-polypoid gastric mucosa
should be sampled to assess the
stage and type of gastritis and,
thus, cancer risk.

Multiple polyps
If multiple polyps, remove the largest and take representative
samples
• Some patients have multiple
polyps, which makes it difficult and
impractical to remove them all.
• The largest polyp should be
excised with representative
biopsies obtained from the
remaining polyps.
• Further management should be
based upon the histology of the
polyp.

Relationship to colonic polyps
If FAP is suspected, colonoscopic investigation is recommended
• In young patients with numerous fundic
glands polyps and not on PPI, FAP should
considered as a possible diagnosis.
• Flexible sigmoidoscopy is usually
recommended.
• Colonoscopy is indicated if there is evidence
of dysplasia

Surveillance
• Repeat gastroscopy should be performed at 1
year for all polyps with dysplasia that have not
been removed.
• Repeat gastroscopy should be performed at 1
year following complete polypectomy for high
risk polyp.

MANAGEMENT OF CERTAIN POLYPS

Hyperplastic polyps
• Simple excision.
• Large (>2 cm) polyps are at increased risk for
malignant transformation and should be
resected completely.
• Test for H. pylori.

Fundic gland polyps
• Biopsy of one or several FGP is sufficient.
• Polyps ≥1 cm in diameter should probably be
removed.
• If multiple, withdrawal of the PPI should be
considered.
• Withdrawal of long term PPI
• As progression to gastric cancer is rare, regular
surveillance is not routinely recommended.

Gastric adenomas
• The cancer risk in dysplasia is sufficiently high to
justify removing all gastric adenomas.
• Synchronous gastric carcinomas: the remainder
of the stomach must be examined carefully.
• Atrophic gastritis: the normal appearing antral
and corpus mucosa should be sampled.
• All patients should be tested for active H. pylori
infection.
• Should have regular endoscopic surveillance.

Gastric carcinoid tumors
• The type Gastric NET should be determined by Bx
of lesion & surrounding mucosa and measure the
fasting serum gastrin level.
• Management depend on tumour type, size of
polyp and presence of metastasis.
• Type 1 : good prognosis, No treatment but if <1
cm →endoscopic resection.
• Type 2: regress if gastrinoma removed.
• Type 3: partial or total gastrectomy with local
lymph node clearance.

Stromal tumour GISTs
• Evaluation by CT & EUS (Local spread/mets).
• If localized →surgical resection.
• If unresectable/ metastasis present→
Imatinib.

Management of Benign epithelial gastric polyps
polyp management
Sporadic fundic glands polyps SFGP Biopsy to confirm nature of polyp
No follow up needed
FAP associated FGP Biopsy to confirm nature of polyp
Repeat OGD every 2 years
Hyperplastic Remove polyp if dysplastic
Eradicate H Pylori
Repeat OGD in one year
Adenoma Remove polyp
Sample rest of gastric mucosa
Repeat OGD in one year
Inflammatory polyps Biopsy to confirm nature of polyp
Remove if causing obstruction
No follow up
©1st Postgraduate course, SSG Feb 13, SAID EM BSG guidelines 2010

Management of gastric polyps associated
with polyposis
Syndrome Life time risk of
malignancy
Surveillance recommendation
FAP 100% (colon) OGD every 2 years after 18
Biopsy > 5 polyps
Remove polyps > 1 cm
Peutz-Jeghers >50% (extra-GI) OGD every 2 years after 18
Biopsy > 5 polyps
Remove polyp > 1 cm
Juvenile polyp >50% OGD every 3 years after 18
Cowden’s Rare Eradicate H pylori
No further OGD needed
©1st Postgraduate course, SSG Feb 13, SAID EM BSG guidelines 2010

Gastric polyp(s)
Forceps biopsy of polyps and surrounding mucosa if suspicion of
non-FGP
adenoma Hyperplastic polyp Fundic gland polyp or
inflammatory fibroid
polyp
With dysplasia
or symptom
Evidence of
H pylori
Repeat the endoscopy
in 1 year
Polyp persist No polyps
Polypectomy if safe to do so
F/U endoscopy in 1 year
Consider FAP.
Consider
polypectomy if
symptomatic
No follow up
BSG guidelines 2010,
management of gastric polyps
and FAP

Summary & recommendations 1
• The incidence and significance of gastric polyps
varies between and among populations.
• Once observed, polyps should be biopsied or
removed if possible.
• If multiple, a representative sample of polyps
should be biopsied.
• Because adenomatous/ hyperplastic polyps are
ass with atrophic gastritis & H. Pylori, normal
appearing mucosa should be sampled and clo
test taken.

• Fundic gland polyps > 1cm should be removed
and if multiple withdrawal of PPI considered.
• Treatment of H Pylori is ass with regression of
polyps in some patients with hyperplastic polyps.
• Due to high risk of cancer, all gastric adenomas
should be removed endoscopically or surgically.
• Management of gastric carcinoid depend on its
type.

Management of gastric polyps

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