management of gastric polyps

Management of Gastric Polyps

Dr Elmuhtady Mohamed Said MRCP MRCPSHonorary Senior Clinical Lecturer, University of Sheffield

Consultant GastroenterologistBarnsley Hospital NHS Foundation Trust, UK

[email protected]©1st Postgraduate course, SSG Feb 13

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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• 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.

Introduction

Arch Pathol Lab Med. 2008 Apr;132(4):633-40©1st Postgraduate course, SSG Feb 13, SAID EM

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• 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.

Epidemiology

Archimandrits A et al, Ital J Gastroentrol 1996;28:1524©1st Postgraduate course, SSG Feb 13, SAID EM

• Frequency and type of gastric polyps vary depending on the population and location.

• Fundic glands polyp common in the West.• Specific genetic mutations are responsible for

polyp formation.

H Pylori commonPPI less common

H Pylori less commonPPI common

Hyperplastic/ adenoma> Fundic Fundic> Hyperplastic/ adenoma

Epidemiology


Different classifications:Histology basedWHO (controversial)

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

BSG Classification


BENIGN EPITHELIAL GASTRIC POLYPS BEGP


Sporadic 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.

Fundic Gland polyps


Sporadic 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.


Fundic Gland polyps

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


• 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.

Hyperplastic 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.

Adenomatous 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.

Hamartomatous polyps


NON-MUCOSAL INTRAMURAL 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.

Inflammatory fibroid polyps


• 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.

Gastric neuroendocrine tumour NETs


• 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.

Stromal tumour GISTs


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


• 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.

Polyp Histology All gastric polyps should be biopsied and examined microscopically for histologic characterization due to risk of cancer.


• 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.

H.Pylori infection All patients with hyperplastic gastric polyps should be tested for H. pylori, if positive, treated with eradication therapy.


• 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.

Gastric mucosa histology


Take biopsy of the normal mucosa

• 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.

Multiple polyps


If multiple polyps, remove the largest and take representative samples

• 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

Relationship to colonic polyps


If FAP is suspected, colonoscopic investigation is recommended

• 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.

Surveillance


MANAGEMENT OF CERTAIN POLYPS


• Simple excision. • Large (>2 cm) polyps are at increased risk for

malignant transformation and should be resected completely.

• Test for H. pylori.

Hyperplastic 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.

Fundic gland polyps


• 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 adenomas


• 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.

Gastric carcinoid tumors


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

Imatinib.

Stromal tumour GISTs


Management of Benign epithelial gastric polypspolyp management

Sporadic fundic glands polyps SFGP Biopsy to confirm nature of polypNo follow up needed

FAP associated FGP Biopsy to confirm nature of polypRepeat OGD every 2 years

Hyperplastic Remove polyp if dysplasticEradicate H PyloriRepeat OGD in one year

Adenoma Remove polypSample rest of gastric mucosaRepeat OGD in one year

Inflammatory polyps Biopsy to confirm nature of polypRemove if causing obstructionNo follow up

BSG guidelines 2010©1st Postgraduate course, SSG Feb 13, SAID EM

Management of gastric polyps associated with polyposis

Syndrome Life time risk of malignancy

Surveillance recommendation

FAP 100% (colon) OGD every 2 years after 18Biopsy > 5 polypsRemove polyps > 1 cm

Peutz-Jeghers >50% (extra-GI) OGD every 2 years after 18Biopsy > 5 polypsRemove polyp > 1 cm

Juvenile polyp >50% OGD every 3 years after 18

Cowden’s Rare Eradicate H pyloriNo further OGD needed

BSG guidelines 2010©1st Postgraduate course, SSG Feb 13, SAID EM

Gastric polyp(s)

Forceps biopsy of polyps and surrounding mucosa if suspicion of non-FGP

adenoma Hyperplastic polyp Fundic gland polyp or inflammatory fibroid

polypWith 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

No follow up

Consider FAP.Consider polypectomy if symptomatic

BSG guidelines 2010, management of gastric polyps and FAP


• 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.

Summary & recommendations 1



• 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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