Successful treatment of proton pump inhibitor induced sporadic fundic gland polyps with an argon plasma coagulator in a patient with polycythaemia vera

Proton Pump Inhibitor-Related Gastric Mucosal Changes

Proton pump inhibitors (PPIs) are used worldwide to treat of acid-related disorders such as peptic ulcer and gastroesophageal reflux disease and to prevent gastroduodenal injuries due to nonsteroidal anti-inflammatory drugs. PPIs are the most potent inhibitors of gastric acid secretion currently available, and they are one of the most commonly prescribed classes of drugs because of their high efficacy and low toxicity. However, long-term PPI use causes histopathological changes such as parietal cell protrusion into the gland lumen, cystic dilation of gastric fundic glands, and foveolar epithelial hyperplasia. These changes can manifest on endoscopic examination as fundic gland polyps, hyperplastic polyps, multiple white and flat elevated lesions, cobblestone-like mucosa, or black spots. Clinicians must be aware of PPI-induced endoscopic features in patients with chronic long-term PPI use. Conversely, identifying patients with long-term PPI use based on their endoscopic findings is important. Recently, potassium-competitive acid blockers (P-CABs), a new class of acid suppressants that inhibit gastric acid secretion more strongly than PPIs, have recently been introduced clinically. Further long-term prospective studies on these gastric mucosal lesions in patients with either PPI or P-CAB use are required to investigate their association with histopathological changes and to establish the clinical significance of these findings. (Gut Liver 2021;15:-652)

Changes of Gastric Juice Microenvironment in Patients with Fundic Gland Polyp and Hyperplastic Polyp

INTRODUCTION

The aim of this study was to study the relationship between the formation of gastric fundic gland polyp and gastric hyperplastic polyp (HP) and the changes of gastric juice microenvironment.

METHODS

The proton-pump inhibitor (PPI) applications to patients were recorded. Gastric juices and biopsy polyps were collected for pathological examination, H. pylori tests, biomarkers, and MUC1, MUC2, MUC5AC expression measurement.

RESULTS

Among 34,892 patients, the detection rate of gastric fundic gland polyps was significantly higher than that of gastric HPs (p < 0.01). The incidence rate of gastric fundic gland polyp and gastric HP in PPI users (n = 3,886) was higher than that of non-PPI users (p < 0.01). The occurrence of polyp was positively related to the duration of PPI application and the H. pylori-positive rate. The bile reflux rate between fundic gland polys group (17.61%) and HPs (28.67%) was significantly different (p < 0.01). The levels of gastric juice Gastrin-17, epidermal growth factor (EGF) and MUC2 from patients with gastric fundic gland polyps and gastric HPs were higher than those in the control group (p < 0.01). However, patients with gastric fundic gland polyps and HPs had significantly lower gastric juice PGE2 and MUC5AC (p < 0.01).

CONCLUSION

PPI application, H. pylori infection, and bile reflux are the potential risk factors for formation of fundic gland polyps and HPs. The potential mechanism of polyps' formation can be related to the levels of Gastrin-17, EGF, MUC2, PGE2, and MUC5AC in gastric juice.

Proton-pump inhibitor-induced fundic gland polyps with hematemesis

Fundic gland polyps (FGPs) are generally considered benign. Proton-pump inhibitors (PPIs) are used worldwide as first-line therapy for gastroesophageal reflux disease and nonsteroidal anti-inflammatory drug-induced ulcer treatment. Long-term use of PPIs increases the risk of FGP development. We report an extremely rare case of PPI-induced FGPs with hematemesis. A 37-year-old woman taking daily rabeprazole presented to the hospital with a complaint of hematemesis and tarry stools. Esophagogastroduodenoscopy (EGD) revealed > 20 pedunculated polyps in the gastric body and fundus. Histological examination showed multiple fragments of fundic gland mucosa with dilated glands. Based on these findings and the clinical history, FGPs were diagnosed. Rabeprazole use was discontinued. Repeat EGD performed 9 months later showed a significant decrease in the number and size of the polyps. FGPs are small polyps typically located in the gastric corpus and fundus. They are commonly reported in patients in their 60s and predominantly in females. We conclude that PPI use is a risk factor for the development of FGPs and hematemesis.

Sporadic Fundic Gland Polyps and Gastric Acid Suppression Level

BACKGROUND

Fundic gland polyps (FGPs) are a common endoscopic finding and are known to be associated with proton pump inhibitors (PPIs) use. It is not known if their prevalence is affected by gastric acidity levels. This study aimed to assess whether there is a correlation between FGPs and gastric acidity levels as identified on 24-hour ambulatory impedance-pH studies in patients on PPI therapy.

METHODS

We performed a review of 402 consecutive patients who take at least once daily PPI and underwent esophagogastroduodenoscopy with combined impedance-pH studies in the same setting (time and place) between January 2010 and December 2014. Patients were classified into 2 groups based on the presence or absence of biopsy-confirmed FGPs during endoscopy.

RESULTS

Of the 402 patients, 30 (7%) had FGPs. One of these polyps was found with low-grade dysplasia. There was no significant difference of the distributions of the [H⁺] in the FGPs versus the nonpolyp groups (P = 0.741). There was no significant difference between the 2 groups regarding PPI dose frequency regimens (once and twice) (P = 0.074). However, we found weak ordinal association with PPI duration (P = 0.01) (Spearman = 0.1).

CONCLUSIONS

FGPs are common endoscopic lesions. Incidence of dysplasia in FGPs is not only rare, but also of unknown clinical significance. Although they seem to be associated with PPIs, the mechanism remains unclear, as we found no correlation between the presence of FGPs and gastric acid control or PPI dose. Future studies would be useful to elucidate an alternate mechanism.