Gastric hamartomatous polyps in the absence of familial polyposis coli

Ectopic bile duct concomitant with gastric ulcer hemorrhage: report of a case

BACKGROUND

An ectopic bile duct opening into the stomach is a rare congenital anomaly of the biliary system, and thus, there are few case reports with gastric ulcer hemorrhage. Herein, we presented a case of ectopic bile duct concomitant with gastric ulcer hemorrhage.

CASE PRESENTATION

A 75-year-old woman was referred to our hospital because she repeatedly vomited blood and had melena. Endoscopic hemostasis was attempted for hemorrhage from a gastric ulcer located on the anterior wall of the antrum. However, the bleeding was difficult to stop, and a laparoscopic distal gastrectomy was performed. Her postoperative course was uneventful. Pathological examination revealed that the bleeding point was an ectopic bile duct. In retrospect, an annual endoscopy performed at her family clinic had revealed a bulge in the same portion of the stomach. Exposure to bile acids from an ectopic bile duct opening can cause gastric mucosal damage and ulceration.

CONCLUSIONS

Ectopic bile ducts opening into the stomach can cause gastric ulcer and hemorrhage. Hemorrhage from a submucosal ridge with ulcer in the stomach may be rarely related to the presence of ectopic bile ducts.

No transformation of a fundic gland polyp with dysplasia into invasive carcinoma after 14 years of follow-up in a proton pump inhibitor-treated patient: A case report

A fundic gland polyp (FGP) is a common gastric polyp. Intraepithelial neoplasia in FGPs, referred to as FGP with dysplasia, is often seen in patients with familial adenomatous polyposis (FAP). In sporadic FGPs, low-grade dysplasia (LGD) is rare, and high-grade dysplasia (HGD) or carcinoma arising from sporadic FGPs is extremely rare. Because of this rarity, the prognosis and appropriate management of these lesions have not been clarified. In the present case, a sporadic FGP with LGD did not develop into invasive carcinoma, but contained foci of HGD 14 years after diagnosis. The biopsy specimen of the polyp taken at the first esophagogastroduodenoscopy 15 years earlier was diagnosed as FGP without dysplasia. At the second histological examination, LGD was found. Because the polyp increased in size during proton pump inhibitor therapy for 14 years, endoscopic mucosal resection was performed. The pathological diagnosis of the resected specimen was FGP with HGD mixed in LGD, with no invasive carcinoma. Dysplasia in FGPs might have less malignant potential regardless of dysplasia or size.

Solitary gastric Peutz-Jeghers type stomach polyp mimicking a malignant gastric tumor

Most cases of Peutz-Jeghers type polyps of the stomach are associated with mucocutaneous pigmentation and multiple intestinal polyposis. A solitary Peutz-Jeghers type polyp of the stomach is rare. We here report a case of a 71-year-old woman with a solitary Peutz-Jeghers type polyp of the stomach who presented with intolerable epigastric pain and weight loss of 5 kg over the prior two months. During the hospital treatment course for this patient, endoscopic examination revealed a bulging lesion with a central hole, mucosal ulceration, an asymmetrical wall thickness and a narrowing of the gastric lumen. A gastric biopsy further revealed ulceration with moderate dysplasia. The patient received endoscopic ultrasonography which showed a second subepithelial lesion that measured 4 cm × 3 cm. Computed tomography of the abdomen subsequently showed a thickened gastric wall with three visibly enlarged lymph nodes, all greater than 1 cm. The suspected diagnosis was malignant gastric cancer with lymph node metastases. The other lesion, which measured 2 cm × 2 cm × 1 cm was noted in the submucosa of the jejunum during surgery. The patient was treated using a subtotal gastrectomy and partial resection of the jejunal tumor. The final pathological report indicated a gastric Peutz-Jeghers type polyp with proliferation of smooth muscle bundles in the submucosal layer, and hyperplastic glands in the mucosal layer and ectopic pancreas of the jejunum. This is the first reported clinical case of a solitary Peutz-Jeghers type polyp of the stomach accompanying a lymph node enlargement and ectopic pancreas in the jejunum that simulates stomach cancer with lymph node metastases.

Adenocarcinoma derived from gastric hamartomatous polyps

Most hamartomatous polyps in the stomach occur in patients with adenomatous polyposis coli and dysplasia. The authors report a case of a 57-year-old man without prior history of polyposis coli who presented with adenocarcinomas derived from hamartomatous polyps in the stomach. The patient underwent a radical subtotal gastrectomy with Billroth I anastomosis. Pathology revealed adenocarcinomas with moderate differentiation without evidence of lymph node metastasis in 60 nodes. We report a case of gastric cancers arising from de novo gastric hamartomatous polyps.

Smooth Muscle Hamartoma of the Abomasum in a Calf

This report describes a case of smooth muscle hamartoma of the abomasum in a 6-month-old steer humanely killed because of severe pneumonia. At necropsy, marked thickening of the abomasal wall in the area of the pylorus was found. On cut section, the thickness of the submucosal layer, extending from the submucosa to the muscularis propria, was seen to be increased to 3 cm. The upper (i.e., nearest to the gut lumen) half of the sectioned thickening was composed mainly of adipose-like tissue and the lower half mainly of muscle-like tissue. Histologically, the submucosal layer was composed of fibroadipose tissue, within which were embedded, to varying degrees, numerous well-defined, haphazardly oriented, thin to thick bundles of smooth muscle fibres. This appears to be the first report of smooth muscle hamartoma of the stomach or abomasum in animals, including man.

Positive predictive value of endoscopic features deemed typical of gastric fundic gland polyps

BACKGROUND

Fundic gland polyps (FGPs) are now the most common gastric polyp encountered by endoscopists. However, they have minimal clinical significance. If they could be reliably predicted by endoscopic features, it might prevent the need for and cost of biopsy.

GOALS

To determine the positive predictive value of endoscopic criteria deemed characteristic of FGPs.

STUDY

We prospectively identified 56 consecutive patients with one or more gastric polyps deemed typical of FGPs by endoscopic criteria and submitted them for histologic analysis. Patients with familial adenomatous polyposis were excluded.

RESULTS

Histologic examination confirmed that 50 (89.3%) of the 56 polyps were FGPs. Of the six polyps incorrectly predicted to be FGPs, three were determined to be of normal gastric body-type mucosa, one was uninterpretable secondary to squeeze artifact, one was a lymphoid aggregate with mucosal edema, and one was polypoid regenerative mucosa in the setting of chronic active gastritis and Helicobacter pylori infection.

CONCLUSIONS

As sporadic FGPs are common and can be predicted with a high degree of accuracy based on endoscopic evaluation, it may not be necessary to submit them for pathologic examination. This practice would result in cost savings.

Fundic gland polyps are not induced by proton pump inhibitor therapy

It is still unclear whether proton pump inhibitors (PPIs) could cause fundic gland polyps (FGPs) in patients without Helicobacter pylori infection. The frequency of FGPs in patients during PPI therapy has not been compared, however with a control group of patients who did not have H. pylori infection and were not undergoing PPI treatment. In a retrospective 12-month study, the frequency of FGPs in 2,251 patients without H. pylori infection receiving PPI therapy (duration of treatment at least 4 weeks) was compared with a control group of 28,096 patients who did not have H. pylori infection and were not receiving PPI therapy. FGPs were identified with an identical frequency in both groups (5.0% in the control and 5.2% in the PPI group). No significant differences were present between the groups with respect to the presence of gastritis or age or sex. Our study shows that a causal pathogenetic relationship between PPI therapy and FGPs is unlikely.

Sporadic fundic gland polyps: common gastric polyps arising through activating mutations in the beta-catenin gene

Fundic gland polyps (FGPs) are the most common gastric polyps. FGPs traditionally have been regarded as nondysplastic hamartomatous or hyperplastic lesions, but their pathogenesis remains unclear. We have recently shown that somatic adenomatous polyposis coli (APC) gene alterations are frequently present in FGPs associated with familial adenomatous polyposis (FAP), raising the possibility that mutations of the beta-catenin gene affecting the APC/beta-catenin pathway might be involved in the pathogenesis of sporadic FGPs. We analyzed somatic beta-catenin gene mutations in 57 sporadic FGPs from 40 patients without FAP and in 19 FGPs from 13 FAP patients. Direct DNA sequencing of exon 3 encompassing the glycogen synthase kinase-3beta phosphorylation region for beta-catenin was used with confirmation by HIN:fI restriction endonuclease digestion. The foveolar epithelium and dilated fundic glands of the polyps were separately microdissected and analyzed in 22 of 57 sporadic FGPs. Activating beta-catenin gene mutations were present in 91% (52 of 57) of sporadic FGPs. Both the foveolar epithelium and the dilated fundic gland epithelium comprising the polyps were shown to have the same somatic beta-catenin mutation in 21 of 22 (95%) sporadic FGPs. In contrast, beta-catenin gene mutations were not present in any of the 19 FAP-associated FGPs (P: < 0.000001). The high frequency of beta-catenin mutations in sporadic FGPs indicates that these lesions arise through activating mutations of the beta-catenin gene. Beta-catenin mutations in gastrointestinal tract polyps have previously only been demonstrated in a subset of adenomatous (dysplastic) or neoplastic polyps. Sporadic FGPs are therefore the only lesions of the gastrointestinal tract to demonstrate beta-catenin mutations while lacking dysplastic morphology.

Parietal cell protrusions in gastric ulcer disease

Oxyntic mucosal biopsy specimens from patients receiving omeprazole therapy have been described as frequently showing characteristic tonguelike protrusions of parietal cell cytoplasm (PCP) into the gland lumen. Although protrusion of parietal cell cytoplasm is believed to be associated with omeprazole therapy and has been implicated in the histogenesis of fundic gland polyps, we have observed it in a wide variety of different conditions unrelated to peptic ulcer disease or omeprazole therapy. To establish the incidence of PCP and analyze its relationship to gastritis, gland dilatation, cystic change, and fundic gland polyps, we studied 400 gastric mucosal biopsy specimens from gastric ulcer patients who were not receiving omeprazole therapy and who did not receive any medications for at least 2 weeks. Severity of each of these changes was graded on a scale of I to III. PCP was observed in oxyntic mucosal biopsy specimens from 60 (15%) patients and was associated with varying grades of chronic superficial or interstitial gastritis in 25 (Helicobacter pylori was identified in 12). Although chronic atrophic gastritis, cystic change, or fundic gland polyps were not identified in any of the cases with PCP, gland dilatation was present in 25 of 60 (42%) biopsy specimens. No consistent linear correlation was observed between increasing grades of PCP and gastritis or gland dilatation. Our findings of PCP in 15% of gastric ulcer patients who were off all medications for 2 weeks indicate that PCP is not always related to omeprazole usage. It appears to be a change encountered in a wide variety of diverse settings and, therefore, should not be used to monitor omeprazole therapy. In gastric ulcer patients, there is no linear correlation between PCP and gland dilatation or severity of gastritis. The lack of association of PCP with such cardinal features of fundic gland polyps as gland dilatation and cystic change suggests that PCP per se has little if any role in the development of such polyps. The exact clinical and functional significance of PCP remain to be established and merits further investigation.

Clinical evaluation of gastric fundic gland polyps without familial polyposis coli

BACKGROUND

Assessments were made of 63 cases of fundic gland polyposis (FGP) unassociated with adenomatosis coli. These cases were evaluated by radiological examination over 2 years follow-up. All polyps were pathologically confirmed by endoscopic biopsies.

METHODS

Most cases were asymptomatic when diagnosed during mass radiological surveys of the upper gastrointestinal tract. The majority of patients ranged in age from 40-60 years, and the polyps numbered fewer than 20 in 55 cases (87.3%). Polyps were detected in the fundic glands using the congo red test and by biopsies.

RESULTS

All serum gastrin values were within the normal range. During the course of this study, the polyps of 13 cases (20.6%) increased and those of three cases (4.8%) decreased or resolved completely.

CONCLUSION

From these findings it is considered that FGP are observed in stomachs with less atrophy, and that polyps follow courses in which they increase, decrease, disappear, along with atrophy.

Report of three gastric tumors in children

The literature concerning gastric tumors in children is mainly limited to case studies. The authors reviewed 1,403 histological reports of pediatric gastric pathology (covering 10 years) at their institution. There were three gastric tumors of benign histology and no malignant tumors. The first patient was a 9 1/2-year-old boy who presented with several months of symptomatic, pH-probe-confirmed gastroesophageal reflux. He underwent placement of a Toupet antireflux valve. During laparotomy, a submucosal mass was discovered incidentally, on the greater curvature of the stomach. The mass was excised. Pathological examination showed heterotopic pancreas. The second patient, a 15-month-old girl, presented with a short period of vomiting. Results of an upper gastrointestinal series showed gastric outlet obstruction. She underwent laparotomy and was found to have an intussusception of a gastric polyp into the proximal jejunum, and an associated malrotation. Ladd's procedure, gastroduoduodenostomy with reduction of the intussuscepted polyp, and excision of the polyp were performed. Histological examination of the tumor showed hamartoma with hyperplastic elements. The tumor was benign but was regarded as difficult to classify. The third patient, a 6-year-old boy, presented with microcytic anemia. Endoscopy showed multiple friable bleeding gastric masses. He underwent laparotomy, with partial gastrectomy and pyloroplasty. Histological examination showed the tumor to be plasma cell granuloma. The tumor recurred, and the patient required subsequent operative procedures. The authors confirm that gastric tumors in children are rare. Although the tumor histology may be benign, excision of the tumor may require major operative resection.

Three familial cases of fundic gland polyposis without polyposis coli

We report three cases of fundic gland polyposis in the stomach identified in three patients who were related. Grossly the numerous polyps covered an area limited to the body and fundus of the stomach, no polyps were found in the antrum, duodenum, colon, or rectum, and histologically, the gastric lesions consisted of numerous hamartomatous polyps, characterized by proliferation of the fundic and cystic glands. The gastric lesions were identified in families without polyposis coli. This type of fundic gland polyposis has never been documented before in the literature.

Incidence of fundic gland polyps in patients without familial adenomatous polyposis

The incidence of fundic gland polyps was evaluated using a high-resolution videoendoscope. In 1388 upper gastrointestinal endoscopic studies, 26 cases of fundic gland polyps (1.9% of the studied cases) were found. None of these patients had evidence of familial adenomatous polyposis. Fifteen of these patients (58%) had a solitary polyp in the gastric body, most of which were small sessile polyps of less than 2 mm in diameter. The results of this study indicated that a small solitary fundic gland polyp is not a rare gastric lesion and that little relationship exists between these solitary fundic gland polyps and familial adenomatous polyposis.

Gross and histological abnormalities of the foregut in familial adenomatous polyposis: a study from a South East Asian Registry

Polyps in the stomach and duodenum are frequently found in familial adenomatous polyposis. Cancer arising from some of these polyps may be an important cause of death in patients who have had large bowel resections. This study aims to determine the nature and distribution of foregut polyps in Chinese patients. Twenty-five patients with familial adenomatous polyposis were gastroscoped by a single operator using the end viewing video-endoscopy system. Representative biopsies of normal mucosa or polyps where appropriate were taken from the gastric fundus, antrum and the duodenum. Twenty-five patients were studied. Male = 17, female = 8. Median age was 32 years (range = 17-63 yrs). Nineteen patients were found to have macroscopically visible polyps in the foregut. Ten patients had gastric polyps alone, three patients had duodenal polyps alone whilst six patients had both gastric and duodenal polyps. Twelve, one and three patients had more than 20 polyps in the gastric fundus, antrum and duodenum respectively. Only one patient had polyps which were larger than 10 mm. The commonest polyp in the gastric fundus was the fundic gland polyp whilst hyperplastic and adenomatous polyps were the commonest polyps in the gastric antrum and duodenum respectively. Five patients had adenomatous polyps of which four had duodenal adenomas alone whilst one patient had adenomas in the duodenum, gastric antrum and fundus. Seventy-six per cent of our patients with familial adenomatous polyposis had foregut polyposis. Adenomatous polyps were found in 56% of patients with duodenal polyps or 20% of patients with foregut polyps but hyperplastic and hamartomatous polyps occur commonly in patients with familial adenomatous polyposis as well.

Upper gastrointestinal pathology in familial adenomatous polyposis: results from a prospective study of 102 patients

Multiple gastric and duodenal biopsy specimens from 102 asymptomatic patients with familial adenomatous polyposis, taken during a prospective endoscopic screening programme were examined. One hundred patients had microscopic gastroduodenal pathology, often in the absence of macroscopic lesions. Adenomas were found in 94 patients in the duodenum, in the second and third parts. Hyperplasia of villous and crypt epithelium was also seen, sometimes in the absence of adenomas: this may be a precursor of neoplastic change. In the stomach fundic gland polyps were the commonest abnormality, seen microscopically in 44 patients. Chronic antral gastritis was common in patients without fundic polyps. Gastric adenomas were present in six patients, all of whom also had duodenal adenomas. If duodenal adenomas in familial adenomatous polyposis have a similar malignant potential to those in the colorectum sequential endoscopy and biopsy are necessary to detect cancer in these patients.

Clinicopathological features and natural history of gastric hamartomatous polyps

The clinicopathological features, chromoendoscopic findings, and natural history of hamartomatous polyps of the stomach were compared with those of gastric hyperplastic polyps. Hamartomatous polyps were found significantly more frequently in adult females than adult males, and all were found significantly more frequently in adult females than adult males, and all were located in the gastric body or the fundus. In general, the number of polyps per patient was less in older patients. Histologically, all these polyps were formed of cystically dilated oxyntic glands and irregularly deformed oxyntic glands. Chromoendoscopic examinations using Congo red showed that the polyps were associated with extensive acid-secreting areas, were all located in acid-secreting areas, and had an acid-secreting function. Colonoscopy and/or radiologic examinations showed that one or a few polyps were frequently also present in the colons of these patients, but none of the families of the patients had a history of gastrointestinal polyposis. One to 11 years after the initial endoscopy, in seven (50.0%) of 14 patients with hamartomatous polyps followed up, the number of polyps decreased significantly.

Gastric hamartomatous polyp without polyposis coli: radiologic diagnosis

Gastric hamartomatous polyps were found in 25 patients over a period of 4 1/2 years, for an incidence of 11% in all endoscopically biopsied polyps. The number of polyps was fewer than 5 in most patients. All polyps were sessile, sharply demarcated, hemispheric protrusions, measuring up to 10 mm in diameter but most were less than 5 mm. The most characteristic finding differing from hyperplastic polyps, adenoma, and polypoid carcinoma was that hamartomatous polyps were located in the fundic gland mucosa, which was demonstrated as a rugal area on moderately distended double-contrast radiographs.

Solitary polypoid hamartoma of the oxyntic mucosa of the stomach

A solitary pedunculated polyp of the oxyntic mucosa removed from a 66-year-old patient with atrophic gastritis and achlorhydria exhibited distinctive histological features consisting of submucosal, mostly oxyntic-type glands with a smooth muscular framework. Histochemical and immunohistochemical studies demonstrated that the glands were composed of well differentiated chief, parietal, and endocrine cells. Moreover, less frequent glands of the antro-pyloric type were also seen. The lesion was regarded as a previously unrecognized variety of gastric hamartoma.

Natural history of fundic gland polyposis in patients with familial adenomatosis coli/Gardner's syndrome

In order to study the natural history of fundic gland polyposis, 23 patients with familial adenomatosis coli/Gardner's syndrome were examined over a follow-up period ranging from 17 mo to 13 yr (average 6 yr). Examinations included gastric radiography and endoscopy with biopsy. Fundic gland polyps were found in 10 individuals. The size and number of polyps varied considerably. During the follow-up period, there was an increase in number or size of polyps, or both, in 5 patients (aged 8-27 yr), a decrease or disappearance in 2 patients (aged 36 and 41 yr), an initial decrease or disappearance followed by a late-occurring increase in 2 patients (aged 28 and 35 yr), In addition, malignant or adenomatous changes of fundic gland polyps were not observed in any patient. Therefore, fundic gland polyposis in patients with familial adenomatosis coli/Gardner's syndrome may appear as early as 8 yr of age. In some patients there is a gradual increase in number and size of polyps, whereas in others, polyp proliferation ceases and polyps may even decrease in number and size. Our findings indicate that the fundic gland polyposis does not require prophylactic surgery and that careful periodic follow-up should suffice.

Hyperplastic fundic gland polyp of the stomach

A case of a solitary pedunculated gastric polyp occurring in the fundic mucosa of a 47-year-old woman is reported because of its unique morphology. The polyp showed a peculiar lobulated configuration supported by smooth muscle bundles, and its epithelial component was composed mainly of a proliferation of relatively normal but disorganized fundic glands containing variable numbers of mucous, parietal, argyrophile, and chief cells. Although these histologic features may suggest a hamartoma-like quality, the lesion probably represents a peculiar form of localized hyperplastic process of the gastric mucosa exhibiting fundic glandular cell differentiation.

Cystic 'hamartomatous' gastric polyps: a disorder of oxyntic glands

In 1977, Elster et al. described gastric polyps of a new type. These polyps were formed of fundic glandular cysts in otherwise normal gastric mucosa. In this paper a series of 52 cases of this type of polyp are presented. In addition to cysts, polyps contained deformed oxyntic glands and areas where the formation of secondary irregular glands occurred from cysts and from the existing glands. However, all glands and cysts in polyps were composed of normal, but intermixed cells of oxyntic type, suggesting that deranged differentiation of otherwise normal oxyntic glands is the basic mechanism in the pathogenesis of these polyps. Based on these observations, the polyps were considered most likely to be epithelial hamartomas. In agreement with the findings of Elster et al., the present cases showed typical clinical characteristics: three-quarters of patients were females with a peak prevalence in the fifth and sixth decades. Polyps were most often multiple and occurred only in the oxyntic mucosa of the stomach.

Polyps in the acid-secreting area of the stomach

The relation of gastric polyps to acid-secreting mucosa was examined in 120 patients with gastric polyps. Studies were made by the endoscopic Congo red test developed in this clinic. In 23 patients (19.1%) gastric polyps were located in acid-secreting mucosa and may have arisen from normal oxyntic mucosa. These polyps were of two histological types: oxyntic gland polyps containing many parietal cells, and nonoxyntic gland polyps without parietal cells. Only the former type appeared to secrete acid, judging endoscopically from the change of Congo red from red to blue-black on the surface of the polyps after administration of gastrin.