Management of Gastric Polyps Dr Elmuhtady Mohamed Said MRCP MRCPS 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

Management of certain polyps 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 ©1st Postgraduate course, SSG Feb 13, SAID EM

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

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

Epidemiology 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 common PPI less common H Pylori less common PPI common Hyperplastic/ adenoma> Fundic Fundic> Hyperplastic/ adenoma ©1st Postgraduate course, SSG Feb 13, SAID EM

Classification Different classifications: Histology based WHO (controversial) ©1st Postgraduate course, SSG Feb 13, SAID EM

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 ©1st Postgraduate course, SSG Feb 13, SAID EM

Benign epithelial gastric polyps BEGP ©1st Postgraduate course, SSG Feb 13, SAID EM

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. ©1st Postgraduate course, SSG Feb 13, SAID EM

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. ©1st Postgraduate course, SSG Feb 13, SAID EM 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 ©1st Postgraduate course, SSG Feb 13, SAID EM

75 % of gastric polyps in areas where H. pylori is common. 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

Found in the antrum, some occur in the corpus and cardia. 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

Malignant transformation rare. Hamartomatous polyps Rare, Include: Juvenile polyps:solitary, antral, inflammatoty or hamartomatous, no malignant potential. PJS: AD,hamartomatous GI polyps, mucocutan. Pigmentaion , increase risk of cancer. Cowden disease: AD, orocutaneous hamartomatous , extra GI abnormalties. Malignant transformation rare. ©1st Postgraduate course, SSG Feb 13, SAID EM

Non-mucosal intramural polyps ©1st Postgraduate course, SSG Feb 13, SAID EM

Rare, 1% of all gastric 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

Histologically, composed of enterochromaffin-like cells. 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

M>F, typically in the fundus. Submucosal, mucosal Bx inadequate. 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

General management ©1st Postgraduate course, SSG Feb 13, SAID EM

©1st Postgraduate course, SSG Feb 13, SAID EM 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

©1st Postgraduate course, SSG Feb 13, SAID EM General principles Polyp Histology Check for H.Pylori infection Gastric mucosa histology Multiple polyps Relationship to colonic polyps Surveillance ©1st Postgraduate course, SSG Feb 13, SAID EM

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. ©1st Postgraduate course, SSG Feb 13, SAID EM

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. ©1st Postgraduate course, SSG Feb 13, SAID EM

Take biopsy of the normal mucosa 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

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. ©1st Postgraduate course, SSG Feb 13, SAID EM

If FAP is suspected, colonoscopic investigation is recommended 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 ©1st Postgraduate course, SSG Feb 13, SAID EM

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. ©1st Postgraduate course, SSG Feb 13, SAID EM

Management of certain polyps ©1st Postgraduate course, SSG Feb 13, SAID EM

Hyperplastic polyps Simple excision. Large (>2 cm) polyps are at increased risk for malignant transformation and should be resected completely. Test for H. pylori. ©1st Postgraduate course, SSG Feb 13, SAID EM

Biopsy of one or several FGP is sufficient. 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

All patients should be tested for active H. pylori infection. 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

Type 2: regress if gastrinoma removed. 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

Evaluation by CT & EUS (Local spread/mets). Stromal tumour GISTs Evaluation by CT & EUS (Local spread/mets). If localized →surgical resection. If unresectable/ metastasis present→ Imatinib. ©1st Postgraduate course, SSG Feb 13, SAID EM

Management of Benign epithelial gastric polyps Sporadic fundic glands polyps SFGP Biopsy to confirm nature of polyp No follow up needed FAP associated FGP 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 Inflammatory polyps 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) 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

Fundic gland polyp or inflammatory fibroid polyp BSG guidelines 2010, management of gastric polyps and FAP 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 Consider FAP. Consider polypectomy if symptomatic Repeat the endoscopy in 1 year Polyp persist No polyps Polypectomy if safe to do so No follow up F/U endoscopy in 1 year ©1st Postgraduate course, SSG Feb 13, SAID EM

Once observed, polyps should be biopsied or removed if possible. 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

Summary & recommendations 2 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. ©1st Postgraduate course, SSG Feb 13, SAID EM

©1st Postgraduate course, SSG Feb 13, SAID EM