1. Gastric ‘Polyposis’ Case Report Medical Trust Hospital, Kochi

2. Clinical August 2001 Female, 45 Yr Longstanding Dyspepsia Recently diagnosed anemia No GI Bleed, Diarrhea, Constitutional symptoms

3. Clinical H2 blocker therapy in 1992 Self medication : H2 blocker till 1999 1999 : Evaluation UGIE / USG : Report NA CECT Abdomen : Stromal Tumor in D2 PPI course for 1 Mth Self medication with PPI since then

4. Examination & Laboratory Severe pallor Scar of LSCS Rest NAD Hemoglobin : 5.9 gm % Peripheral blood smear : Hypochromic microcytic anemia Routine biochemistry : Normal

5. UGI Endoscopy Markedly hypertrophic gastric mucosal folds Fundus, body studded with polypoid lesions (sessile). Size:0.5-2cm, with umbillication Relative sparing of antrum Smaller umbillicated nodules in antrum and D1. D2 and D3 Normal No E/o Ulcer disease, active or old

6. CECT Thickened gastric wall in fundus and body up to 2 cm 5 cm mass lesion on anterolateral aspect of D2 Pancreas, retroperitoneum, liver normal

7. CECT

10. CECT Jan 2000

11. EUS Submucosal thickening of stomach Mass in relation to D2 with intact serosa Pancreas normal Snare biopsy of polyp

12. EUS

14. Histology Atrophic Gastritis Gastric Carcinoid Immunostaining : Synaptophysin positive

15. Investigations 24 Hr Urinary 5-HIAA : 10.5 mg Normal range (2.0 - 10) Serum Gastrin Assay (After withholding PPI for 1 wk) : 520 pg/ml Normal ( Upto 120 pg) H. Pylori Serology : Negative

16. Surgery Preoperative blood transfusion Total Gastrectomy with excision of ‘paraduodenal mass’. Esophagojejunal pouch anaestomosis Roux en y Findings: Pancreas, D2, Hepatoduodenal ligament, small bowel normal.

17. Specimen

18. Pouchogram

20. Histology Gastric Carcinoid extending upto muscularis at places Atrophic Gastritis Metastatic Lymph node

21. Follow up Asymptomatic (No Dyspepsia !!!) Tolerates near normal size meal Hemoglobin maintained Follow up Gastrin assay awaited Not popping pills

22. Gastric Carcinoid Uncommon Three variants *Type I : Associated with Atrophic Gastritis *Type II : Associated with Gastrinoma *Type III: Sporadic

23. Multiple Gastric Carcinoids Type I and II Associated with hypergastrinemic state Reversal reported on correction of hypergastrinemia with small tumor volume Prognosis better than ‘Sporadic’ variant 5 yr survival 80 -100 % Association with prolonged acid suppression not reported yet in humans