1. 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

2. Management of certain polyps
Introduction
Epidemiology
Classification
General Management
Management of certain polyps
Summary and Recommendations
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3. BSG Guidelines Gut 2010:59:1270-1276.doi:10.1136
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4. =
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 Apr;132(4):633-40

5. 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

6. 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
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7. Classification Different classifications: Histology based
WHO (controversial)
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8. 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
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9. Benign epithelial gastric polyps BEGP
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10. Sporadic Fundic gland polyps
Two types: sporadic or associated with polyposis syndrome.
Typically small ( 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.
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11. 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

12. 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
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13. 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.
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14. 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

15. 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.
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16. Non-mucosal intramural polyps
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17. 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

18. 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

19. 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.
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20. General management
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21. ©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

22. ©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
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23. 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

24. 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

25. 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

26. 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

27. 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
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28. 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.
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29. Management of certain polyps
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30. Hyperplastic polyps
Simple excision.
Large (>2 cm) polyps are at increased risk for malignant transformation and should be resected completely.
Test for H. pylori.
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31. 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.
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32. 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

33. 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

34. 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

35. 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

36. 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

37. 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
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38. 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

39. 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.
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