Abstract:Most gastric polyps have anasymptomatic presentation and are an incidental finding on upper endoscopy.Symptomatic presentations can range from anemia and bleeding up to completegastric outlet obstruction. We present a case presented to us by jaundice,vomiting, and upper abdominal pain for one week. Ultrasound shows a picture ofacute pancreatitis and obstructive jaundice. In gastroscopy, we found a largepedunculated gastric polyp passing through pyloric ring up to 2nd part ofduodenum causing a compression on duodenal papilla. It was pulled back tostomach after grasping with a snare.
Then, it was removed by piecemealtechnique after injection of the pedicle with diluted adrenaline. Bleedingafter snaring the pedicle was secured with injection of diluted adrenaline anda insertion of a haemoclip followed by complete resolution of all symptoms.Introduction:Gastric polyps are found inapproximately 1%–6.
35% of endoscopies (1). Most of thesecases are asymptomatic; however large polyps can be presented by bleeding,anemia, or obstructive symptoms (2). Gastric hamartomatouspolyps comprise about 1% of all the stomach polyps. They can be presentedsolitary or as a part of a clinical syndrome (3) such asPeutz–Jeghers syndrome (PJS) and juvenile polyposis. solitary polyps areusually benign except for inverted hamartomatous polyps (GIHPs), which have a20% of malignant transformation.
In contrast, the syndromatic hamartomatouspolyps has a higher malignancy risk that increases with age (range: 1-33%)between 30 and 60 years (4).Gastric polyps may intussuscept toduodenum causing gastric outlet obstruction. If the prolapsed polyp contains afunctional antral mucosa over it, that mucosa may keep secreting gastrin due tobeing placed in the alkaline media of duodenum. In turn, this hypergastrinemiamay lead to erosion of the prolapsed polyp and blood loss (5).Diagnosis is often done by endoscopy;first case treated by endoscopic treatment modalities was at 1973(6).Management of gastric polyps dependson its type; In hyperplastic polyps conservative medical management andendoscopic surveillance of smaller polyps is preferred while polypectomy is indicatedin large polyps (more than 0.5 cm) forrisk of malignant transformation(7). Case presentation: A 24 years old man was admitted tohospital due to severe persistent vomiting, fatigue, and upper abdominal pain radiatingto the back for one week.
This condition was followed by yellowish discolourationof sclera associated with dark colored urine and low grade fever of no specificpattern. His hemoglobin was 12 g/dL, Total Leucocytic Count: 19000 x109/Lwith marked neutrophilia, Platelets: 340 x109/L.Liver function tests revealed elevated aminotransferases;ALT 168 U/L, AST 137 U/L. And hyperbilirubenemia ; Total bilirubin 9 mg/dl, and direct bilirubin was 7 mg/dl.
Other investigations revealed: Amylase 1300 U/L, Lipase 650 U/L.Abdominal ultrasound revealed bulky pancreas, dilated pancreaticduct, distended gall bladder with mud inside, dilated common bile duct and intrahepatic biliary radicles. The patient was diagnosed as a case obstructivejaundice complicated by acute pancreatitis.Patient was referred for endoscopic retrograde cholangiopancreatographywhich revealed distorted anatomy of stomach and large polyp occupying the 2ndpart of duodenum preventing the scope from reaching papilla. Gastroscopy wasdone, violaceous colored twisted pedicle passing thorough pylorusto 2nd part of duodenum where a large pedunculated polyp partiallyobstructing the lumen.
This polyp (12×8 cm in size) was originated from stomachpassing down to the 2nd part of duodenum. It was pulled back to stomach after beinggently grasped with large snare (Figure 1).The biopsies taken were reported as hamartoumatous gastricpolyp. It was removed using piecemeal technique after injection of the pedicle with diluted adrenaline.
Bloodspurting after snaring the pedicle was secured with injection of dilutedadrenaline and application of a haemoclip (Figure 2). Histopathology revealedhamartomous polyp.The patient kept NPO for 48 hrs under coverage of IVfluids, proton pump inhibitor and antibiotic (Imipenam). His symptoms wererelieved, his leuocytic count and bilirubin started to decline. 10 days later,the patient was quite well, freely consumed a normal diet and had normalleucocytic count, bilirubin, ALT, AST, amylase and lipase. Screeningcolonoscopy was normal. Figure 1 : Lagre gastric polyp after pulling inside stomach Figure 2: Extraction of polyp and hemoclip insertion Discussion: In literature there is no recordedcases of such a complication of a gastric polyp; Most recorded cases of giantgastric polyps developed a picture of intermittent gastric obstruction.Meta-analysis was done in 2010 for giant gastric polyp complications; about 40 cases were reviewed and showed oldage and female predominance, most of these polyps were hyperplastic (90% of cases) (8).
However the recorded cases of solitary hamartomatous polyps are more prevalentin younger age (median age 43.5) with female predominate as well (9).Hamartomatous polyps are composed ofepithelial elements and bundles of smooth muscle cells. Proliferation ofmuscularis mucosa is a classic feature. (10).Endoscopic management is preferred forlarge polyps, large prolapsed polyps can be dragged into stomach for easing thepolypectomy procedure, instead of performing it in bulbus, which is a narrower space than stomach(11).
Multiple endoscopic techniques areused for polypectomy of hamartomatous polyps; Endoscopic mucosal resection(EMR) are preferred for sessile polyps however in pedunculated polyps electrocautery snare polypectomy is done withusage of hypertonic saline epinephrine injection, endoloops, band ligation, andendoscopic haemoclips for control of bleeding. In our case, we used thecombined methods for high risk bleeding control (diluted adrenaline and haemoclip)with successful control of bleeding (12).Larger sessile polyps have a greaterpropensity to bleed because of larger feeding vessels. Endoscopic ultrasound(EUS) would theoretically minimize the risk of bleed by visualizing the bloodvessels at the base of the gastric polyp. Surgical interference was done onlyin complicated cases (13).
Conclusion: Gastric hamartomatous polyps are rarecondition. Large polyps may be precancerous for which endoscopic resection ispreferred, screening other family members is mandatory in syndromic hamaromatouspolyposis.