Proton pump inhibitors and an emerging epidemic of gastric fundic gland polyposis

Updated European guidelines for clinical management of familial adenomatous polyposis (FAP), MUTYH-associated polyposis (MAP), gastric adenocarcinoma, proximal polyposis of the stomach (GAPPS) and other rare adenomatous polyposis syndromes: a joint EHTG-ESCP revision

BACKGROUND

Hereditary adenomatous polyposis syndromes, including familial adenomatous polyposis and other rare adenomatous polyposis syndromes, increase the lifetime risk of colorectal and other cancers.

METHODS

A team of 38 experts convened to update the 2008 European recommendations for the clinical management of patients with adenomatous polyposis syndromes. Additionally, other rare monogenic adenomatous polyposis syndromes were reviewed and added. Eighty-nine clinically relevant questions were answered after a systematic review of the existing literature with grading of the evidence according to Grading of Recommendations, Assessment, Development, and Evaluation methodology. Two levels of consensus were identified: consensus threshold (≥67% of voting guideline committee members voting either 'Strongly agree' or 'Agree' during the Delphi rounds) and high threshold (consensus ≥ 80%).

RESULTS

One hundred and forty statements reached a high level of consensus concerning the management of hereditary adenomatous polyposis syndromes.

CONCLUSION

These updated guidelines provide current, comprehensive, and evidence-based practical recommendations for the management of surveillance and treatment of familial adenomatous polyposis patients, encompassing additionally MUTYH-associated polyposis, gastric adenocarcinoma and proximal polyposis of the stomach and other recently identified polyposis syndromes based on pathogenic variants in other genes than APC or MUTYH. Due to the rarity of these diseases, patients should be managed at specialized centres.

The Impact of Sex on the Response to Proton Pump Inhibitor Treatment

Proton pump inhibitor (PPI) treatment is responsible for substantial gastrin elevation secondary to reduced intragastric acidity. Due to the increasing global prevalence of PPI users, concerns have been raised about the clinical significance of continuous gastrin elevation and its potential long-term side effects. Hypergastrinemia secondary to PPIs has trophic effects on gastric mucosa, leading to enterochromaffin-like cell hyperplasia and gastric (fundic) polyp formation, and it is believed to provoke acid rebound following PPI withdrawal that induces PPI overutilization. Previous studies have found higher gastrin release following PPI therapy in females compared with males, and sex differences have also been demonstrated in pharmacokinetic parameters and dose requirements for acid reflux. It is conceivable that females might be at increased risk of PPI overuse, because they often receive higher milligram-per-kilogram doses. The prevalence of PPI use is more common among females, and the female sex is a risk factor for adverse drug reactions. This non-systematic review outlines the current knowledge of the impact of biological sex on the response to PPIs. The aim is to highlight the female sex as a potential risk factor that could be a step toward precision medicine and should be considered in future research on the response to PPI treatment.

Forty years of Helicobacter pylori infection and changes in findings at esophagogastroduodenoscopy

BACKGROUND

It is 40 years since the discovery of Helicobacter pylori infection. Over that time major changes have occurred in esophagogastroduodenoscopy (EGD) findings. The aim of this review is to describe these changes, and the important role H. pylori infection has played in their evolution.

METHODS

References were identified through searches of PubMed using the search terms-endoscopy time trends, peptic ulcer disease, gastroesophageal reflux disease, upper gastrointestinal cancer, gastric polyps, H. pylori, eosinophilic gastrointestinal disorders, and celiac disease, from 1970 through December 2021.

RESULTS

The prevalence of H. pylori infection has fallen and consequently, H. pylori-positive peptic ulcer disease has become rare. Gastroesophageal reflux disease is now the commonest disorder diagnosed at EGD, and Barrett's esophagus has increased in parallel. Cancer of the distal stomach has fallen while esophageal adenocarcinoma and reflux-related cardia cancer have risen. Gastric polyps have changed from hyperplastic and adenomas to sporadic fundic gland polyps. Antimicrobial resistance has made H. pylori infection more difficult to eradicate. Eosinophilic gastrointestinal disorders, particularly eosinophilic esophagitis, have emerged as important new allergic disorders. Celiac disease has changed and increased.

CONCLUSIONS

EGD findings appear to have changed from features suggesting a H. pylori-positive "phenotype" 40 years ago to a H. pylori-negative "phenotype" today. These changes have major implications for the management of gastrointestinal disorders.

Early Prophylactic Gastrectomy for the Management of Gastric Adenomatous Proximal Polyposis Syndrome (GAPPS)

Background

Gastric adenomatous proximal polyposis syndrome (GAPPS) is a recently described, rare, autosomal dominant condition characterized by the extensive involvement of the proximal stomach with hundreds of heterogeneous fundic gland polyps with antral and duodenal sparing. GAPPS is caused by a point mutation of the APC gene promoter 1B and is associated with a risk of malignant transformation, distant metastasis, and death. There are no surveillance, screening, or treatment guidelines for managing GAPPS. The few reported cases have been variably managed with endoscopic surveillance or prophylactic gastrectomy. However, there is no consensus on the optimal management approach.

Summary

In this case series, we review the relevant literature on GAPPS and present two siblings who underwent early prophylactic total gastrectomies with good outcomes.

Conclusion

Due to the poor correlation between the endoscopic findings on sampled polyps and the risk of harboring invasive gastric cancer, patients with GAPPS should be strongly considered for early prophylactic total gastrectomies in the absence of prohibitive comorbidities.

Familial and hereditary gastric cancer, an overview

There are three major hereditable syndromes that affect primarily the stomach: hereditary diffuse gastric cancer (HDGC), gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS) and familial intestinal gastric cancer (FIGC). HDGC is caused by germline mutations in CDH1 gene that occur in 10-40% of HDGC families and, in a minority of cases, by mutations in CTNNA1 gene. GAPPS is caused by germline mutations in the promoter 1B of APC gene, and the genetic cause of FIGC is not fully elucidated. Gastric cancer can also be observed as part of other inherited cancer disorders, namely in familial adenomatous polyposis, MUTYH-associated polyposis, Peutz-Jeghers syndrome, juvenile polyposis syndrome, Lynch syndrome, Li-Fraumeni syndrome, Cowden syndrome, and hereditary breast and ovarian cancer syndrome. In this article, the state of the art of familial gastric cancer regarding the clinical, molecular and pathology features is reviewed, as well as the practical aspects for a correct diagnosis and clinical management.

Gastric polyps: a 10-year analysis of 18,496 upper endoscopies

Background/aims

Gastric polyps (GPs) are usually asymptomatic lesions of the upper gastrointestinal tract observed in 1–3% of esophagogastroduodenoscopies (EGD). Most GPs are benign. The aim of this study was to precise the frequency of different types of gastric polyps in our population, and to analyze their possible association with other factors.

Materials and methods

A total of 18,496 consecutive patients undergoing EGD over a 10-year period (between 2007 and 2018) in a tertiary hospital were retrospectively reviewed. Eighty-six patients diagnosed with gastric polyps were analysed. Demographics, medical history of the patients, and indication for gastroscopy were collected. Morphological, histological characteristics of polyps, and therapeutic management data were also collected.

Results

GPs were found in 86 out of 18,496 (0.46%) reviewed EGD, corresponding to a total of 141 polyps. There were 64 female (74.4%) and 22 male patients (25.6%) with a sex ratio (M/F) of 0.34. The average age was 58.1 years. One hundred and forty one polyps were included, and histopathology was obtained on 127 GPs. The most common location was the fundus (59.6%) and 48.9% were smaller than 5 mm. The polyp was unique in 75.6% of cases. According to Paris classification, 80% of the polyps were sessile (Is). Hyperplastic polyps were the most common (55.9%), followed by sporadic fundic gland polyps observed in 23 patients (18.1%), 7 (5.5%) were adenomas and 4 (3.1%) were neuroendocrine tumors type 1. The following factors were associated with hyperplastic polyps: anemia (p = 0.022), single polyp (p = 0.025) and size ≥ 5 mm (p = 0.048). Comparing hyperplastic polyps’ biopsies to resected polyps, no difference was found in the evolutionary profile of the 2 groups. A size less than 10 mm (p = 0.013) was associated with fundic gland polyps. Sixty polyps (47.2%) were treated by cold forceps, 19 (15%) treated by a mucosal resection and 15 (11.8%) with diathermic snare. Five procedural bleeding incidents were observed (3.9%). Only the use of anticoagulant treatment was associated with a high bleeding risk (p = 0.005). The comparative histological study between specimens of biopsied GPs and endoscopic polypectomy led to an overall agreement of 95.3%.

Conclusion

In our study, the GPs frequency was 0.36%. Hyperplastic polyps and fundic gland are the most common in our country. The high frequency of Helicobacter pylori infection in our patients and in our area may explain the high frequency of HP.

Case Series: Development of Polyps as a Late Effect After Total Body Irradiation-based Hematopoietic Cell Transplantation in Children With High-risk Leukemia

Advancements in hematopoietic cell transplantation (HCT) have led to increased survivorship rates in many childhood diseases. However, this growing group of long-term survivors face a myriad of late effects. There are currently limited guidelines for surveillance of gastrointestinal polyps for pediatric transplant patients. Here we describe 5 patients undergoing HCT with total body irradiation-based conditioning regimens for leukemia who developed symptomatic polyps a median of 4.5 (range: 0.75 to 5.75) years after HCT. Because of limited surveillance guidelines in children, we conclude that the development of new or progressive symptoms related to the gastrointestinal tract deserves prompt recognition and evaluation.

Gastric Acid Powered Nanomotors Release Antibiotics for In Vivo Treatment of Helicobacter pylori Infection

Helicobacter pylori (H. pylori) infection has ≈75% probability of causing gastric cancer, so it is considered to be the strongest single risk factor for gastric malignancies. However, the harsh gastric acid environment has created obstacles to medical treatment. This work reports a nanomotor with a bottle-shaped container that can be loaded with small molecules of clarithromycin, nano calcium peroxide (CaO₂ ), and Pt nanoparticles (Pt NPs) by ultrasound. Nanomotors can quickly consume gastric acid through the chemical reaction of CaO₂ to temporarily neutralize gastric acid. The product hydrogen peroxide (H₂ O₂ ) is catalytically decomposed into a large amount of oxygen (O₂ ) by Pt NPs. The local concentration gradient of O₂ bubbles causes it to be expelled from the nanobottles through a narrow opening, and then push the nanobottles forward to provide maximum release and prodrug efficacy. Experiments in animal models show that 15 mg nanomotors can safely and quickly neutralize gastric acid in the stomach and simultaneously release prodrugs to achieve good therapeutic effects without causing acute toxicity. H. pylori burden in mice was 2.6 orders of magnitude lower than that in the control group. The stomach returns to normal pH within 1 d after administration.

Recent advances in the pathology of heritable gastric cancer syndromes

Despite the relative rarity of hereditary gastric cancer syndromes, the prompt recognition of their specific clinical features and histopathological characteristics is pivotal in offering patients the most appropriate treatment. In this article, we address the three major inherited syndromes that primarily affect the stomach: hereditary diffuse gastric cancer (HDGC), caused by germline variants in CDH1 and CTNNA1; gastric adenocarcinoma and proximal polyposis of the stomach, caused by germline mutations in promoter 1B of APC; and familial intestinal gastric cancer, which has a poorly defined genetic cause. The main focus will be on HDGC, in light of the recent publication of updated clinical practice guidelines and emerging concepts regarding HDGC histopathology. In particular, we describe the broad morphological spectrum of HDGC lesions, stressing the importance of recognising indolent and aggressive phenotypes. Moreover, we discuss the increased risk of gastric (pre)malignancies developing in patients with other well-defined hereditary cancer syndromes, such as familial adenomatous polyposis, Lynch syndrome, Peutz-Jeghers syndrome, juvenile polyposis, Li-Fraumeni syndrome, and hereditary breast and ovarian cancer syndrome.

GASTRIC FUNDIC GLAND POLYPS: CAN HISTOLOGY BE USEFUL TO PREDICT PROTON PUMP INHIBITORS USE?

BACKGROUND

Fundic gland polyps allegedly increased in frequency in recent decades, and had attracted great attention due to possible association with prolonged proton pump inhibitor therapy. Prolonged use of this drug could cause parietal cell hyperplasia, obstruction of glandular lumen and cystic dilation of the gland.

OBJECTIVE

This study aims to analyze clinical and pathological features of fundic gland polyps in patients with and without proton pump inhibitor therapy in a selected population from Brazil.

METHODS

It was selected a sample of 101 Brazilian patients (78 females and 23 males), from a five years retrospective search of the files from a private pathology laboratory. The patients had an average age of 57 years and we included patients with a histological diagnosis of fundic gland polyp. The clinical data were obtained from their files and all histological slides were reviewed and examined with hematoxylin and eosin (HE) and Giemsa.

RESULTS

Information about the use or non-use of proton pump inhibitors (PPI) was obtained in 84 patient files. In 17 cases we could not determine if PPI were used or not. Among those in which the information was available, a positive history of anti-acid therapy was observed in 63 (75.0%) patients. Parietal cell hypertrophy/hyperplasia and parietal cell protrusions were detected in most slides. Histological findings were identical in PPI users and PPI negative patients. Helicobacter pylori infection was detected in just two samples. Epithelial dysplasia or adenocarcinoma were not observed in our cases. Histopathological analysis of fundic gland polyps could not distinguish between PPI and non-PPI related cases. Parietal cell cytoplasmic protrusions, an alleged marker of prolonged acid suppression therapy, was detected in both groups.

CONCLUSION

Histological features could not discriminate anti-acid therapy related fundic glands polyps in our patients.

The Prevalence and Risk Factors of Gastric Polyp in Asymptomatic Patients Receiving Health Examination

Background

To determine the risk factors and prevalence of asymptomatic gastric polyps in the general population of Taiwan.

Methods

Consecutive asymptomatic individuals completing a health examination during October 2015–March 2016 were enrolled in the study and subjected to upper GI endoscopy. Their demographic data and medical history were collected, and the prevalence of gastric polyps was calculated. The risk factors of gastric polyps were identified by analyzing these data through univariate and multivariate logistic regression.

Results

Gastric polyp prevalence in the study population was 29.8%. Age range of 45–60 years, current smoking, and lack of regular exercise were found to be significantly associated with gastric polyps, whereas age range of 45–60 years (relative risk [RR], 1.59; 95% confidence interval [CI], 1.06–2.40) and current smoking (RR, 1.63; 95% CI, 1.04–2.55) were found to be independent predictors for gastric polyps.

Conclusions

In Taiwan, asymptomatic gastric polyps have a prevalence of 29.8%. Age range of 45–60 years and current smoking may increase the risk of asymptomatic gastric polyps.

Gastric adenocarcinoma and proximal polyposis of the stomach: diagnosis and clinical perspectives

Gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS) is a recently described, rare gastric polyposis syndrome. It is characterized by extensive involvement of the fundus and body of the stomach with fundic gland polyps sparing the antrum and lesser curvature, an autosomal dominant inheritance pattern with incomplete penetrance, and a significant predisposition for the development of gastric adenocarcinoma. Due to the recent discovery of APC promotor IB mutations (c.-191T>C, c.-192A>G, and c.-195A>C), which reduce binding of the transcription factor Yin Yang 1 (YY1) and transcriptional activity of the promotor, as its underlying genetic perturbation, GAPPS has been added to the growing molecular class of APC-associated disorders. Recent reports on family members afflicted by gastric polyposis due to GAPPS have described the development of metastatic cancer or the presence of invasive gastric adenocarcinoma in total gastrectomy specimens after variable periods of endoscopic surveillance emphasizing the need for an improved understanding of the to-date poorly characterized natural history of the syndrome. There are, however, currently no guidelines on screening, timing of prophylactic gastrectomy, or endoscopic surveillance for GAPPS available. In this review, we summarize the clinical, pathological, and genetic aspects of GAPPS as well as management approaches to this rare cancer predisposition syndrome, highlighting the need for early recognition, a multidisciplinary approach, and the creation of prospective family registries and consensus guidelines in the near future.

FANCA D1359Y mutation in a patient with gastric polyposis and cancer susceptibility: A case report and review of literature

Gastric polyposis is a rare disease. Not all polyps progress to cancer. Monoallelic mutation in Fanconi anemia (FA) genes, unlike biallelic gene mutations that causes typical FA phenotype, can increase risks of cancers in a sporadic manner. Aberrations in the FA pathway were reported in all molecular subtypes of gastric cancer. We studied a patient with synchronous gastric cancer from gastric polyposis by conducting a 13-year long-term follow up. Via pathway-driven massive parallel genomic sequencing, a germline mutation at FANCA D1359Y was identified. We identified several recurrent mutations in DNA methylation (TET1, V873I), the β-catenin pathway (CTNNB1, S45F) and RHO signaling pathway (PLEKHG5, R203C) by comparing the genetic events between benign and malignant gastric polyps. Furthermore, we revealed gastric polyposis susceptible genes and genetic events promoting malignant transformation using pathway-driven targeted gene sequencing.

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.

Nilotinib Induced Recurrent Gastric Polyps: Case Report and Review of Literature

Patient: Male, 62

Final Diagnosis: Chronic myeloid leukemia

Symptoms: Gastric polyps

Medication: Nilotinib

Clinical Procedure: —

Specialty: Hematology

Point Mutations in Exon 1B of APC Reveal Gastric Adenocarcinoma and Proximal Polyposis of the Stomach as a Familial Adenomatous Polyposis Variant

Gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS) is an autosomal-dominant cancer-predisposition syndrome with a significant risk of gastric, but not colorectal, adenocarcinoma. We mapped the gene to 5q22 and found loss of the wild-type allele on 5q in fundic gland polyps from affected individuals. Whole-exome and -genome sequencing failed to find causal mutations but, through Sanger sequencing, we identified point mutations in APC promoter 1B that co-segregated with disease in all six families. The mutations reduced binding of the YY1 transcription factor and impaired activity of the APC promoter 1B in luciferase assays. Analysis of blood and saliva from carriers showed allelic imbalance of APC, suggesting that these mutations lead to decreased allele-specific expression in vivo. Similar mutations in APC promoter 1B occur in rare families with familial adenomatous polyposis (FAP). Promoter 1A is methylated in GAPPS and sporadic FGPs and in normal stomach, which suggests that 1B transcripts are more important than 1A in gastric mucosa. This might explain why all known GAPPS-affected families carry promoter 1B point mutations but only rare FAP-affected families carry similar mutations, the colonic cells usually being protected by the expression of the 1A isoform. Gastric polyposis and cancer have been previously described in some FAP-affected individuals with large deletions around promoter 1B. Our finding that GAPPS is caused by point mutations in the same promoter suggests that families with mutations affecting the promoter 1B are at risk of gastric adenocarcinoma, regardless of whether or not colorectal polyps are present.

Resolution of Fundic Gland Polyposis following Laparoscopic Magnetic Sphincter Augmentation and Subsequent Cessation of Proton Pump Inhibitors

Gastric polyps occur from a variety of sources and are found commonly on upper endoscopy. We present the case of a 49-year-old female who presented for evaluation for antireflux surgery with a history of fundic gland polyposis who required twice-daily proton pump inhibitors (PPIs) for control of her gastric reflux. After verifying that she met criteria for surgery, she underwent an uncomplicated laparoscopic magnetic sphincter augmentation placement. With the cessation of PPIs following surgery, the fundic gland polyposis resolved. Fundic gland polyps may occur sporadically or within certain syndromes, such as familial adenomatous polyposis. Multiple possible inciting factors exist, including the use of PPIs. This is the first reported case of the resolution of numerous fundic gland polyps following the completion of laparoscopic magnetic sphincter augmentation.

Gastro-oesophageal reflux in young babies: who should be treated?

Recent guidelines focus on a non-interventionist approach to management of gastro-oesophageal reflux in infancy and emphasise the importance of explanation, reassurance and simple measures such as attention to feeding. Relying on clinical history alone leads to over diagnosis of disease, and widely used medications are often ineffective for symptom relief and carry significant risk of harm. The association between vomiting in infancy and other problems such as crying and poor feeding should not be interpreted as implying causality. When there are strong pointers to underlying gastro-oesophageal reflux disease, invasive investigations are required in order to formulate appropriate intervention.

ENDOSCOPIC AND HISTOPATHOLOGIC GASTRIC CHANGES IN CHRONIC USERS OF PROTON-PUMP INHIBITORS

Background Proton-pump inhibitors have been used for at least two decades. They are among the most commonly sold drugs in the world. However, some controversy remains about the indications for their use and the consequences of their prolonged use. Objectives To evaluate and compare the endoscopic and histopathologic gastric changes in chronic users of proton-pump inhibitors to changes in non-users. Methods A prospective study performed at a tertiary Public Hospital involving 105 patients undergoing upper-gastrointestinal endoscopy. Subjects included 81 proton-pump inhibitor users and 24 non-users (control group). Biopsies of the antral-type mucosa, the antral-fundic transition, and the fundus were evaluated by the Sydney System. The presence of erosion or ulceration, lymphatic follicles, reactive gastropathy, and polypoid or epithelial hyperplasia was also determined. Serum levels of gastrin were measured. Results We found two polyps, one in each group, both of which were negative for Helicobacter pylori. There were two cases of parietal cell hyperplasia in users of proton-pump inhibitors. Gastrin was elevated in 28 users of proton-pump inhibitors and in four members of the control group. We did not find statistically significant differences in the endoscopic or histopathologic findings between the two groups. Conclusions Chronic use of proton-pump inhibitors for the duration examined was not associated with significant gastric changes. An interesting finding was that the 4 chronic users of proton-pump inhibitors who had serum gastrin levels above 500 pg/mL also had positive serology for Chagas disease.

Mucosal expression of aquaporin-4 in the stomach of histamine type 2 receptor knockout mice and Helicobacter pylori-infected mice

BACKGROUND AND AIM

Basolateral water channel, aquaporin-4 (AQP4), is known to be expressed in gastric parietal cells, especially in the basal side of gastric mucosa. However, the role of AQP4 in the stomach is still unknown. Histamine type 2 receptor (H2R) knockout mice, which are characterized by suppressed gastric acid secretion, are known as formation of mucosal hyperplasia with cystic dilatation and spasmolytic polypeptide-expressing metaplasia (SPEM) in the stomach. The aim of the present study is to investigate whether the expression of AQP4 is changed by the condition of acid suppression and Helicobacter pylori infection.

METHODS

Male H2 R knockout mice and their controls (C57BL/6) were used. H. pylori was orally infected at the age of 5 weeks. The distributions of AQP4 and H+/K+-ATPase in the gastric mucosa were investigated by fluorescent immunohistochemistry. The mRNA expressions of AQP4, H+/K+-ATPase, sonic hedgehog (Shh), and trefoil factor-2 (TFF2) were investigated by quantitative reverse transcription polymerase chain reaction (RT-PCR).

RESULTS

In the H2 R knockout mice, the distribution of AQP4-positive parietal cells was extended toward the surface of the fundic glands. Although the mRNA expression levels of AQP4 and H+/K+ATPase were elevated in H2 R knockout mice at the age of 20 weeks, the elevations were not maintained by aging or H. pylori infection. In H2 R knockout mice with H. pylori infection, the expression level of TFF2 mRNA was elevated while the ratio between AQP4 and H+/K+ ATPase mRNA expression was decreased compared with the H2 R knockout mice without H. pylori infection.

CONCLUSIONS

In the H2 R knockout mice, massive SPEM was induced by H. pylori colonization and the ratio between AQP4 and H+/K+ATPase mRNA expression was decreased.

Relative risk factors associated with the development of fundic gland polyps

OBJECTIVES

The prevalence of fundic gland polyps (FGPs) is increasing. Some researchers consider this increase to be associated strongly with the long-term use of proton-pump inhibitors (PPIs); however, not all researchers share this belief. There are minimal data on the development of FGPs in China. Therefore, we aimed to investigate the prevalence of FGPs and risk factors associated with the development of this disease.

MATERIALS AND METHODS

We studied 10 904 consecutive patients who underwent gastroduodenal endoscopies at our digestive endoscopy center between February 2011 and January 2013. Information on sex, age, Helicobacter pylori infection, PPIs intake, and the pathological results of the polyps were collected in the FGPs group and in the control group. The use of PPIs, sex, and H. pylori infection were statistically evaluated as dichotomous variables using a χ-test; age was evaluated as a continuous variable using a t-test. Finally, these factors were evaluated using a multiple logistic regression analysis.

RESULTS

Gastric polyps were found in 759 (7.0%) patients, and 213 (2.0%) of these patients had FGPs. FGPs accounted for 28.1% of the gastric polyps. In the FGPs group, the percentage of H. pylori infection was 66.8% and the percentage of PPIs intake for at least 12 months was 23.1%. In the control group, the percentage of H. pylori infection was 77.4% and the percentage of PPIs intake for at least 12 months was 2.3%. The difference in the long-term use of PPIs was statistically significant between these two groups [χ=33.98, P<0.05, odds ratio (OR)=12.83, 95% confidence interval (CI): 4.47-36.80]. The results of the logistic regression were as follows: long-term use of PPIs (P<0.01, OR=14.11, 95% CI: 4.15-47.93); age (P<0.01, OR=1.69, 95% CI: 1.31-2.18). The P-values for sex and H. pylori infection were higher than 0.05.

CONCLUSION

Age and the long-term use of PPIs were risk factors for the presence of FGPs; the long-term use of PPIs was a particularly strong risk factor.

Fatal Spontaneous Clostridium septicum Gas Gangrene: A Possible Association With Iatrogenic Gastric Acid Suppression

The long-term use of proton pump inhibitors has been linked to an increased risk for the development of gastric polyps, hip fractures, pneumonia, and Clostridium difficile colitis. There is evidence that chronic acid suppression from long-term use of proton pump inhibitors poses some risk for the development of C difficile–associated diarrhea by decreasing the elimination of pathogenic microbes before reaching the lower gastrointestinal tract. Here we present a case of a 51-year-old woman with a recent history of abdominal pain and fever who presented to the emergency department with rapidly progressive spontaneous necrotizing fasciitis and gas gangrene and died within hours of presentation. Postmortem examination confirmed spreading tissue gas gangrene and myonecrosis. In addition, multiple intestinal ulcers containing Clostridium septicum were present at autopsy. This case illustrates a possible association between proton pump inhibitor therapy and fatal C septicum infection.

[Prevalence of gastric polypoid lesions at an endoscopic facility]

BACKGROUND

The prevalence of gastric polyps is unknown in Hungary.

AIM

The aim of the authors was to assess the prevalence of polypoid lesions of the stomach in the endoscopic centre of the 2nd Department of Medicine, Semmelweis University.

METHODS

Results of upper gastrointestinal endoscopies carried out between March 2010 and June 2011 were analysed.

RESULTS

193 cases with polyps were diagnosed in 4174 endoscopies (4.62%). Hyperplastic polyps, fundic gland polyps and malignant lesion were detected in 33.67%, 31.09% and 2.07% of the cases, respectively. Proton pump inhibitor use was more frequent among patients diagnosed with fundus gland polyps (p = 0.007), while hyperplastic polyps were diagnosed more frequently in patients with chronic gastritis (p = 0.032).

CONCLUSIONS

The frequency of gastric polyps was higher than expected from data published in the literature. Long-term proton pump-inhibitor use and chronic gastritis were associated with fundus gland and hyperplastic polyps, respectively.

Acid suppressive drugs and gastric cancer: A meta-analysis of observational studies

AIM: To evaluate the association between acid suppressive drug use and the development of gastric cancer.

METHODS: A systematic search of relevant studies that were published through June 2012 was conducted using the MEDLINE (PubMed), EMBASE, and Cochrane Library databases. The search included observational studies on the use of histamine 2-receptor antagonists (H₂RAs) or proton pump inhibitors and the associated risk of gastric cancer, which was measured using the adjusted odds ratio (OR) or the relative risk and 95%CI. An independent extraction was performed by two of the authors, and a consensus was reached.

RESULTS: Of 4595 screened articles, 11 observational studies (n = 94558) with 5980 gastric cancer patients were included in the final analyses. When all the studies were pooled, acid suppressive drug use was associated with an increased risk of gastric cancer risk (adjusted OR = 1.42; 95%CI: 1.29-1.56, I² = 48.9%, P = 0.034). The overall risk of gastric cancer increased among H₂RA users (adjusted OR = 1.40; 95%CI: 1.24-1.59, I² = 59.5%, P = 0.008) and PPI users (adjusted OR = 1.39; 95%CI: 1.19-1.64, I² = 0.0%, P = 0.377).

CONCLUSION: Acid suppressive drugs are associated with an increased risk of gastric cancer. Further studies are needed to test the effect of acid suppressive drugs on gastric cancer.

Acute WNT signalling activation perturbs differentiation within the adult stomach and rapidly leads to tumour formation

A role for WNT signalling in gastric carcinogenesis has been suggested due to two major observations. First, patients with germline mutations in adenomatous polyposis coli (APC) are susceptible to stomach polyps and second, in gastric cancer, WNT activation confers a poor prognosis. However, the functional significance of deregulated WNT signalling in gastric homoeostasis and cancer is still unclear. In this study we have addressed this by investigating the immediate effects of WNT signalling activation within the stomach epithelium. We have specifically activated the WNT signalling pathway within the mouse adult gastric epithelium via deletion of either glycogen synthase kinase 3 (GSK3) or APC or via expression of a constitutively active β-catenin protein. WNT pathway deregulation dramatically affects stomach homoeostasis at very short latencies. In the corpus, there is rapid loss of parietal cells with fundic gland polyp (FGP) formation and adenomatous change, which are similar to those observed in familial adenomatous polyposis. In the antrum, adenomas occur from 4 days post-WNT activation. Taken together, these data show a pivotal role for WNT signalling in gastric homoeostasis, FGP formation and adenomagenesis. Loss of the parietal cell population and corresponding FGP formation, an early event in gastric carcinogenesis, as well as antral adenoma formation are immediate effects of nuclear β-catenin translocation and WNT target gene expression. Furthermore, our inducible murine model will permit a better understanding of the molecular changes required to drive tumourigenesis in the stomach.

Use of Proton Pump Inhibitor and Risk of Colorectal Cancer: A Meta-analysis of Observational Studies

Background

Previous case-control studies have reported inconsistent findings regarding the association between proton pump inhibitor (PPI) use and colorectal cancer (CRC) risk. We investigated these associations using meta-analysis.

Methods

We searched MEDLINE (PubMed), EMBASE, and the Cochrane Library in April 2011. Two evaluators independently reviewed and selected articles, based on pre-determined selection criteria.

Results

Out of 737 articles meeting our initial criteria, 5 case-control studies, which involved 120,091 participants (9,514 cases and 110,577 controls), were included in the final analyses. The overall use of PPI (used vs. never or rarely used) was not significantly associated with the risk of CRC in a fixed-effects model meta-analysis of all 5 case-control studies (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.96 to 1.20; I² = 3.5%). Also, in sensitivity meta-analysis by cumulative duration of PPI use, there was no association between PPI use of 1 year or longer and the risk of colorectal cancer in a fixed-effects meta-analysis (OR, 1.09; 95% CI, 0.98 to 1.22; I² = 0%).

Conclusion

Although hypergastrinemia could be an important factor in the pathogenesis of some colorectal cancers, our study suggests that this does not lead to significant clinical risk for most PPI users. Further prospective studies or randomized controlled trials related to PPI use and colorectal cancer risk are needed to investigate this association.

The changing histological pattern of gastric polyps in an ethnically heterogeneous population

BACKGROUND AND AIM

Variation in the prevalence of various types of gastric polyps worldwide may reflect different etiologies. Here, the authors report the dynamic changes in histological distribution of gastric polyps over time and by ethnicity for individuals who underwent gastroscopies between 1994 and 2009 at two hospitals in Jerusalem, Israel. During this time period, the proportion of patients receiving proton pump inhibitors (PPIs) increased while the proportion of patients infected with Helicobacter pylori (H. pylori) decreased.

PATIENTS AND METHODS

Pathological reports of biopsies from 50,071 consecutive gastroscopies were reviewed.

RESULTS

Gastric polyps were detected in 727 individuals. The yearly prevalence of gastric polyps was ≤ 1% between 1994 and 2001 and ≥ 2% from 2004 to 2009, of which overall 66% were hyperplastic polyps and 23% fundic gland polyps (FGPs). FGPs were diagnosed exclusively in the Jewish population. From 2001 to 2004, an increase in the absolute number of newly discovered hyperplastic and FGPs per year was observed. However from 2005, a divergent trend of changes was observed: While the proportion of patients with hyperplastic polyps dropped from 0.72 during the 2001-2004 period to 0.62 during the 2005-2009 period (p = 0.02), the proportion of patients with FGPs at these time periods increased from 0.16 to 0.33 (p = 0.0001).

CONCLUSIONS

The yearly prevalence of gastric polyps in Jerusalem has recently doubled. This occurred mainly due to the increasing prevalence of FGPs. The changing epidemiology of gastric polyps is probably related to the interaction between genetic factors and fluctuating environmental factors like H. pylori infection rates and exposure to PPIs.

Distribution trends of gastric polyps: an endoscopy database analysis of 24 121 northern Chinese patients

BACKGROUND AND AIM

Traditionally the most common gastric polyps are hyperplastic polyps (HPs). However, in the last two decades, fundic gland polyps (FGPs) have greatly increased in Western countries. We aimed to re-evaluate and compare the distribution of gastric polyps in a northern Chinese population in 2000 and 2010.

METHODS

Consecutive patients with gastric polyps detected in 2000 and 2010 were analyzed and biopsies were re-evaluated. Data including patients' age, sex, symptoms and the number, size, location, Helicobacter pylori (H. pylori) infection of polyps were recorded.

RESULTS

A total of 6784 and 17 337 patients underwent esophagogastroduodenoscopy in 2000 and 2010, 68 and 183 patients were diagnosed with gastric polyps, respectively. H. pylori infection decreased from 54.4% to 37.7% (P = 0.017). Overall, spectrum of gastric polyps changed (P < 0.001). HPs accounted for 28.3% and decreased from 48.5% to 20.8%, adenoma/carcinoma and inflammatory polyps also decreased. FGPs were present in 50.6% and increased from 8.8% to 66.1%. The location of polyps was also changed with an increase of polyps in gastric corpus. There was a high proportion of FGPs in females, while adenomas/adenocarcinomas were more common in males. The distribution pattern was similar in young and elderly patients.

CONCLUSIONS

Spectrum change of gastric polyps was observed over the past 10 years in the northern Chinese population most likely due to the higher proportion of FGPs. Further studies are required to investigate the reasons and confirm whether it will lead to a different management strategy in China.

[Massive fundic gland polyposis caused by chronic proton pump inhibitor therapy]

We report two cases of a massive fundic gland polyposis associated with protracted proton pump inhibitor (PPI) therapy. Both patients were females aged 51. On repeated endoscopy, the number of fundic gland polyps was increasing steeply, and they resulted in a passage disorder. In the first case, the enormous number of polyps made endoscopic removal impossible, so the patient was treated by total gastrectomy. Although our case is the second one reported in the world, we would like to draw the attention to this rare complication of long lasting PPI therapy.

Fundic gland polyps and association with proton pump inhibitor intake: a prospective study in 1,780 endoscopies

BACKGROUND AND AIMS

Fundic gland polyps (FGPs) are incidentally found when an endoscopy is performed for a non-related indication. Some authors suggested a relationship with proton pump inhibitor (PPI) intake. We aimed to determine their prevalence and association with PPI intake.

METHODS

We prospectively studied 1,780 patients who underwent a gastroduodenal endoscopy at our ambulatory care center between June 2007 and August 2008. PPI intake during a period of at least 12 months, female gender and age were statistically evaluated as risk factors for the presence of FGPs. Then, a multiple logistic regression analysis was applied to these variables.

RESULTS

Gastric polyps were found in 129 patients (7.2%) and 77 (4.33%) were FGPs. Five patients with no available histology were excluded for the assessment of risk factors. PPI intake was detected in 49 patients with FGPs (63.6%) and 264 without FGPs (15.5%) (P < 0.0001). Fifty-nine patients with FGPs (76.7%) and 987 without FGPs (58.1%) were women (P < 0.001). The mean age was 58.91 ± 11.82 years in patients with FGPs and 50.34 ± 15.04 years in patients without FGPs (P < 0.0001). The three variables remained significant in the multiple model: PPI intake: P < 0.0001, OR 9.00 (95% CI 5.44-14.89); female gender: P = 0.0001, OR 2.95 (95% CI 1.69-5.15); age: P = 0.001, OR 1.03 (95% CI 1.01-1.05).

CONCLUSIONS

In our population, the prevalence of FGPs was high. Although female gender and age were also significant, PPI intake was the strongest risk factor associated with the presence of FGPs.

Gastroduodenal mucosa in microscopic colitis

BACKGROUND

We have assessed gastroduodenal, endoscopical and histopathological findings in a series of patients with microscopic colitis (MC).

METHODS

We studied 75 patients with MC, 27 with collagenous colitis (CC) and 48 with lymphocytic colitis (LC), and 60 controls. Data of endoscopical findings were collected and biopsies were assessed.

RESULTS

Helicobacter pylori infection rate was 15% in MC and 28% in the controls (p = 0.088). Age at diagnosis of MC was higher in H. pylori positive than negative patients (63.4 ± 9.6 vs. 54.4 ± 13.1 years; p = 0.034). Gastric endoscopic erosions were more prevalent in CC than in LC (25.9% vs. 6.2%; p = 0.030) and associated with thick body glands and antral predominance of gastritis in H. pylori positive patients. Rates of focal gastritis (5.6% vs. 6.9%) and lymphocytic gastritis (5.6% vs. 10%) were similar in MC and controls. LC was associated with gastric epithelial lymphocytosis and lymphocytic gastritis. Fifteen patients (20%) had celiac disease.

CONCLUSIONS

Unlike LC, CC is associated with endoscopic erosions, likely related with the high acid secretion capacity as indicated by the ample body glands and antral predominance of gastritis in H. pylori associated cases of CC. The presence of some divergent gastroduodenal features in LC and CC, and in comparison with those reported in inflammatory bowel disease (IBD), supports the concept that these two conditions differ not only from IBD but also from each other. The findings also suggest the presence of pathogenetic links between colorectal and gastroduodenal abnormalities.

Acid suppression by proton pump inhibitors enhances aquaporin-4 and KCNQ1 expression in gastric fundic parietal cells in mouse

BACKGROUND

The widespread use of proton pump inhibitors (PPIs) is known to cause sporadic gastric fundic gland polyps (FGPs). Altered expression and localization of the water or ion transport proteins might contribute to the excess fluid secretion into the cystic lumen for the development of FGPs.

AIMS

We investigated the alteration of the murine gastric fundic mucosa after PPI treatment, and examined the expression of water channel aquaporin-4 (AQP4) and potassium channel KCNQ1, which are expressed only in the parietal cells in the gastric mucosa.

METHODS

Male 5-week-old C57BL/6J mice were administered lansoprazole (LPZ) by subcutaneous injection for 8 weeks. The expression of AQP4 and KCNQ1 were investigated by Western blotting, quantitative RT-PCR, and immunohistochemistry. The expression of mucin-6 (Muc6), pepsinogen, and sonic hedgehog (Shh) were also investigated as mucosal cell lineage markers.

RESULTS

Gastric mucosal hyperplasia with multiple cystic dilatations, exhibiting similar histological findings to the FGPs, was observed in the LPZ-treated mice. An increase in the number of AQP4-positive parietal cells and KCNQ1-positive parietal cells was observed. The extension of the distribution of AQP4-positive cells toward the surface of the fundic glands was also observed. The expression levels of AQP4 mRNA and protein were significantly enhanced. The expression of KCNQ1 mRNA was correlated with that of AQP4 mRNA in the LPZ-treated mice. Mucous neck-to-zymogenic cell lineage differentiation was delayed in association with decreased expression of Shh in the LPZ-treated mice.

CONCLUSIONS

PPI administration increased the number of parietal cells with enhanced expression of AQP4 and KCNQ1.

A case of gastric polyposis in antral area of stomach following prolonged proton-pump therapy

We describe the clinical scenario of a young male with history of non ulcer dyspepsia who had endoscopic evidence of gastric polyposis in antral area. The polyps disappeared four months after proton pump inhibitors were stopped. Proton pump inhibitors have been linked to gastric fundal polyposis and not antral gland polyposis. This is the first report originating from an Asian country describing antral gland polyposis (AGPs) in a patient on long-term PPI therapy with no evidence of Helicobacter pylori. A case report with brief review is presented.

Prevalência de alterações proliferativas gástricas em pacientes com uso crônico de inibidores de bomba de prótons

RACIONAL: As medicações mais frequentemente prescritas e usadas de forma crônica por pacientes com queixas dispépticas pertencem ao grupo dos inibidores de bomba de prótons cujo principal representante é o omeprazol, utilizado clinicamente a cerca de 20 anos. Estudos recentes têm postulado a relação entre o uso crônico desta medicação e alterações proliferativas macroscópicas e microscópicas da mucosa do fundo e corpo gástrico, principalmente os pólipos de glândulas fúndicas. OBJETIVO: Analisar a frequência e o tipo de alterações proliferativas gástricas em usuários crônicos de inibidores de bomba de prótons e sua associação com idade, dose utilizada, tempo de uso, sintomatologia e infecção pelo Helicobacter pylori. MÉTODO: Estudo transversal de prevalência realizado no Serviço de Endoscopia Digestiva do Hospital de Clínicas da Universidade Federal do Paraná. Aplicado questionário com informações quanto ao uso destas drogas e realizada endoscopia digestiva alta em sujeitos em uso contínuo desta classe de medicamentos há pelo menos 12 meses. Realizadas biópsias de fundo, corpo e antro gástrico em todos os pacientes. Pólipos eram retirados ao serem identificados, para análise histopatológica. Realizada pesquisa do Helicobacter pylori por teste de urease e análise histopatológica. RESULTADOS: Vinte e dois indivíduos foram incluídos sendo que seis (27,3%) apresentaram alterações proliferativas da mucosa oxíntica. Destes, dois (9,1%) apresentavam pólipos fúndicos esporádicos e quatro apresentavam exclusivamente alteração proliferativa microscópica como formação cística glandular. Houve significância estatística (p<0,05) na associação entre idade > 60 anos e estas alterações. Não houve associação entre dose de uso, tempo de uso, sintomatologia e infecção pelo Helicobacter pylori. CONCLUSÕES: Ocorrem alterações proliferativas de mucosa oxíntica em indivíduos em uso crônico de inibidores de bomba de prótons. A associação entre idade e alterações proliferativas apresentou significância estatística.

Gastric foveolar metaplasia and gastric heterotopia in the duodenum: no evidence of an etiologic role for Helicobacter pylori

Gastric-type epithelium and islands of oxyntic mucosa in duodenal biopsies are considered by some to be part of a spectrum of metaplastic change related to peptic disorders. This study was designed to assess prevalence and associations of metaplastic-heterotopic gastric mucosa in the duodenum. Demographic, clinical, and histopathologic data from patients who had duodenal biopsy specimens for a 12-month period were collected from a national database. The duodenal findings of patients with duodenitis, gastric metaplasia, and gastric heterotopia were correlated with gastric pathology, Helicobacter pylori status, and clinical information. Of 28,210 patients with duodenal biopsy specimens, 80.9% were healthy, 2.1% had active duodenitis, 2.2% gastric foveolar metaplasia without active inflammation ("peptic duodenopathy"), 4.8% gastric foveolar metaplasia with active inflammation ("peptic duodenitis"), and 1.9% gastric heterotopia. Helicobacter pylori was documented in 9.8% of patients with normal duodenum, 6.9% of those with gastric metaplasia without active inflammation, 15.8% of those with active duodenitis, and 29.1% of those with gastric foveolar metaplasia with active inflammation; 2.2% of 543 patients with gastric heterotopia had H pylori gastritis. Helicobacter pylori was detected in the metaplastic epithelium of 67.6% of patients with active inflammation and in 16.4% of those with metaplasia without inflammation. Gastric heterotopia was strongly associated with concurrent fundic gland polyps. In conclusion, active duodenitis was more common in patients with H pylori infection, but gastric metaplasia was not. We suggest that there is insufficient evidence to ascribe duodenitis with foveolar metaplasia to a "peptic" disorder, as "peptic duodenopathy" and "peptic duodenitis" seem to imply. Gastric heterotopia is likely a congenital lesion; its association with fundic gland polyps suggests that use of proton pump inhibitors may enhance its endoscopic detection.

Chronic proton pump inhibitor therapy associated with increased development of fundic gland polyps

BACKGROUND

Fundic gland polyps (FGP) have been implicated with long-term proton pump inhibitor (PPI) use.

AIMS

We attempted to investigate the impact of length and dosage of PPI therapy on the development of FGP.

METHODS

A retrospective cohort study of all patients who had gastric polyps removed during elective upper endoscopy between March and September 2007 as part of a prior prospective study protocol was carried out. FGP were determined histologically. Prior to endoscopy, all patients completed a questionnaire regarding PPI use and length of therapy (no PPI use, 1-48 months, >48 months). The dosage of PPI was obtained via a thorough chart review of electronic medical records.

RESULTS

Three hundred and eighty-five patients completed upper endoscopy and a questionnaire reporting PPI use (252 [65.4%] patients on PPI). On endoscopy, 55 patients had polyps, with the majority (43/55, 78%) being FGP, resulting in an overall prevalence of 11.1% (43/385). On univariate analysis, FGP were associated with Caucasian race (15 vs. 6%; P=0.009) and chronic PPI therapy (>48 months) (31.9 vs. 7.5%, P<0.001). There was a significant linear-by-linear association between PPI dosage and FGP prevalence (no PPI use, 7.5%; once daily, 10.8%; twice daily 17.4%, P=0.026). On logistic regression, the only independent predictor of FGP was duration of PPI use >48 months (P=0.001, odds ratio [OR] 4.7 [2.0-12.9]).

CONCLUSIONS

The only independent predictor of FGP development in our study was duration of PPI therapy greater than 48 months. Increased dosage of therapy did not significantly impact the development of FGP.

Plugs clog the glandular outlets in fundic gland polyps

A systematic histologic analysis of 62 gastric fundic gland polyps (FGP) was carried out. All FGP (100%) showed foveolar cells with hypertrophic cytoplasm. In 95% of the FGP, parietal cells ballooned into the lumen and in 93%, exfoliated anucleated structures with eosinophilic granules were found. Plugs of anucleated structures with eosinophilic granules, most likely derived from exfoliated parietal cells, were found to clog the outlets of the glands in 86% of the FGP. None of the 30 control gastric biopsies without FGP had similar cellular aberrations. FGP seems to evolve by cellular aberrations affecting parietal cells. This is not surprising considering that genetic mutations are recorded in FGP with a common APC/b-catenin pathway in both FAP and sporadic cases. The genetic mutations in FGP might alter the biological behavior of the parietal cells, leading to increased exfoliation with clogging of the outlets of the glands. Thus, the blocking of the glandular outflow by plugs of anucleated structures with eosinophilic granules is the most likely cause for the cystic accumulation of "normal" glandular secretions.

No association between gastric fundic gland polyps and gastrointestinal neoplasia in a study of over 100,000 patients

BACKGROUND & AIMS

Fundic gland polyps (FGPs), the most common type of gastric polyps, have been associated with prolonged proton pump inhibitor therapy and an increased risk of colon cancer. The presence of FGPs has been inversely correlated with Helicobacter pylori infection. We evaluated the prevalence of H pylori-associated gastritis, colonic polyps, and carcinomas in subjects with and without FGPs.

METHODS

We analyzed data collected from community-based endoscopy centers in 36 states (plus Washington DC and Puerto Rico) on patients who underwent esophagogastroduodenoscopy (EGD) and colonoscopy between April 2007 and March 2008. Of the 103,385 patients who underwent EGD during this time period, gastric biopsy samples were collected from 78,801 and colonic biopsies from 26,017. Slides of samples from Helicobacter-infected FGPs and FGPs with dysplasia were reviewed.

RESULTS

FGPs were detected in 6081 patients (67.8% women). Helicobacter infection was present in less than 0.5% patients with FGPs and 13.0% of those without FGPs (odds ratio [OR], 29.05; 95% confidence interval [CI], 20.4-41.4; P < .0001). Colonic adenomas were detected in 42.3% of women with FGPs and 33.8% of those without (OR, 1.43; 95% CI, 1.26-1.63; P < .001); there was no significant difference in colonic adenomas between men with and without FGPs.

CONCLUSIONS

Women had a higher prevalence of FGPs. FGPs were associated with gastroesophageal reflux disease symptoms, gastric heterotopia, hyperplastic colonic polyps (only in men), and colonic adenomas (only in women, especially those over 60 years of age). The presence of FGPs was inversely correlated with H pylori infection, active gastritis, and gastric neoplasia.

The current spectrum of gastric polyps: a 1-year national study of over 120,000 patients

OBJECTIVES

To use a large pathology database (Caris Diagnostics) to analyze the frequency and associations of gastric polyps in a nationwide US population.

METHODS

A total of 121,564 esophagogastroduodenoscopy (EGD) procedures from private practices in 36 states in the Caris Diagnostics database from 1 April 2007 to 31 March 2008 were searched for the endoscopic designations of polyp, nodule, and mass, and for the pathological diagnoses that commonly present as gastric polyps. Pertinent demographic data, clinical indications for EGD, and information regarding Helicobacter pylori infection, reactive gastropathy, chronic inactive gastritis, and intestinal metaplasia were also obtained.

RESULTS

A total of 78,909 of the 121,564 patients who underwent EGD had gastric biopsies. The prevalence of gastric polyps in the EGD population was 6.35%; 77% were fundic gland polyps, 17% hyperplastic polyps/polypoid foveolar hyperplasia, 0.69% adenomas, and 0.1% inflammatory fibroid polyps. Malignant neoplasms were slightly >2%. None of the benign gastric polyps had a significant positive association with concurrent H. pylori infection; intestinal metaplasia was detected in the background of 52.2% of carcinoids, 29.6% of adenomas, 20.1% of xanthomas, and 13% of adenocarcinomas and hyperplastic polyps. Adenomas were rarely associated with synchronous adenocarcinomas.

CONCLUSIONS

The relative prevalence of fundic gland polyps in this population was much higher than that reported earlier, most likely because of the widespread use of proton pump inhibitors. H. pylori- and atrophy-associated polyps, including adenomas, were less common than in earlier series.

[Gastric polyposis due to treatment with proton pump inhibitors]

Fundic gland polyps can appear sporadically or in association with familial adenomatous polyposis syndrome. An association between fundic gland polyps and prolonged treatment with proton pump inhibitors has been described, as has their regression after withdrawal of these inhibitors. Dysplastic components are not usually associated. We describe four patients who were receiving chronic treatment with proton pump inhibitors. The results of prior endoscopic analysis were normal. The presence of multiple fundic gland polyps was detected as was their disappearance 6 months after treatment cessation.