1. CLINICAL GASTROENTEROLOGY&
HEPATOLOGY 2013;11:1374–1384
Supervisor:
Dr.Mohamed AlShekhani
Management of Gastric Polyps:
An Endoscopy-Based Approach
Kurdistan Board gastroenterology weekly
Journal club.

2. Gastric polyps: the 3 main types.
FGPs
HPPs
ADPs

3. An abnormal growth of tissue projecting
from the gastric mucosal membrane.

4. Fundal gland polyps:
Now the most frequent in West BZ of wide
PPIs Use
Hyperplastic polyps: the 2nd most common
polyps notable for their association with
gastritis& their low but important potential
for harboring dysplastic or neoplastic foci
Adenomas: now raised intraepithelial
neoplasia ,decreasing in parallel with HP;
important as harbingers of GC, sp in E Asia.
GIST have low incidence, no known
associations, malignant potential
is high; early diagnosis&proper
management are crucial.

5. Inflammatory fibroid polyps:
Should be recognized, particularly by
pathologists, to avoid misdiagnosis.
Gastric neuroendocrine tumors (carcinoids)
important because of their association with
either atrophic gastritis or MEN syndromes;
those do not arise in these backgrounds
have high malignant Potential & require
aggressive management.

6. Polyps that reveal a malignancy upon
histopathologic exam lose their polyp
status, irrespective of their initial
endoscopic appearance.
Lesions (eg, lipomas, heterotopias,
leiomyomas) are unlikely to cause clinical
dilemmas.

7. Fundic gland polyps:
The most common type of polyps detected
at EGD in West.
6% of EGDs
74% of all gastric polyps submitted for HP.
Endoscopically, usually multiple,
small (1 cm), smooth, glassy, sessile.
By NBI a honeycomb appearance with
dense vasculature(nonspecific also seen in
hyperplastic polyps).

8. Fundic gland polyps:
Histology
consist of one or more dilated oxyntic
glands, lined by flattened parietal&mucous
cells .
Among the most characteristic lesions of
the stomach.
Regenerative appearance may be
misinterpreted as dysplasia.
True dysplasia, particularly high grade, is
exceedingly rare and is virtually limited to
fundic gland polyps found in patients with
polyposis syndromes.

9. Fundic gland polyps: clinical approach
1 or more should undergo biopsy.
Large polyps (1 cm) ,ulcerated, > 20, unusual
location as antrum should prompt a more
aggressive approach.
Biopsy is not adequate because may not
include dysplasia or neoplasia.
When found in a young , esp
if numerous (eg, 20),possibility of polyposis
should be considered.
Individuals with FAP typically are <40,
occasionally have polyps in the antrum.
When gastric polyps are associated
with duodenal adenomas a familial
polyposis syndrome strongly should be
considered &colonoscopy recommended.

10. Fundic gland polyps: clinical approach
If FGPs > 20 or > 1 cm & on PPI.
Withdraw PPI & see if number or size
reduced.
If so & still need for PP,give I MINIMAL
effective dose or change to another PPI or
H2RBs.
Measure serum gastrin.
Exclude gastrinoma.

11. Hyperplastic Polyps
Inflammatory proliferations of gastric foveolar cells (mucinproducing epithelial cells lining gastric surface& pits).
inflammatory polyps or foveolar.
Occur in patients with post-Billroth I & II gastric stumps
exposed to bile.
The classic association with mucosal atrophy, whether H
pylorior autoimmune-induced.
Now more with normal mucosa without HP.

12. Hyperplastic Polyps
Equally common in men & women
typically occur in the sixth&seventh decades ( 66 y).
Endoscopically, most frequently in antrum,often multiple.
Usually smooth, dome-shaped, 0.5-1.5 cm, may be larger.
Large hyperplastic polyps often become lobulated,
Pedunculated, surface typically is eroded
result in chronic blood loss & IDA, Rarely, if large GOO.
The overall prevalence of carcinoma in hyperplastic
polyps is <2%, > ]in polyps >2 cm.

13. Hyperplastic Polyps
>1 cm should be excised completely.
If dysplasia or intramucosal carcinoma is found, but the stalk
is not affected, the lesion considered completely cured.
Excision accompanied by additional sampling of the
unaffected mucosa from the antrum&corpusto to obtain
reliable information about the topography/severity of the
background gastritis & atrophy.
When hyperplastic polyps arise in a background of chronic
atrophic gastritis (a precursor lesion for gastric
adenocarcinoma) the severity and extent of the atrophic
gastritis should be evaluated, using the Operative Link for
Gastritis Assessment (OLGA) or the Operative Link on
Gastritis/Intestinal Metaplasia Assessment staging systems.
Preferably 7-biopsy , 3 specimens from the antrum
(which can be submitted in a single formalin container), 2
from the lesser curvature, 2 from the greater
curvature, with each set in a separate container.

14. Hyperplastic Polyps
If present, H pylori should be eradicated &endoscopic
follow-up evaluation should be scheduled between 3 & 6
months after therapy to confirm successful eradication.
Alternatively, noninvasive test as the urea breath test used.
Patients with OLGA stages III and IV (moderate diffuse
atrophy or severe atrophy in either the corpus or antrum,
usually accompanied by extensive intestinal metaplasia)
should be considered for longterm endoscopic surveillance.

15. Hyperplastic Polyps
If present, H pylori should be eradicated &endoscopic
follow-up evaluation should be scheduled between 3 and 6
months after therapy to confirm successful eradication.
Alternatively, noninvasive test as the urea breath test used.
Patients with OLGA stages III and IV (moderate diffuse
atrophy or severe atrophy in either the corpus or antrum,
usually accompanied by extensive intestinal metaplasia)
should be considered for longterm endoscopic surveillance.

16. Gastric Adenomas (Raised Intraepithelial
Neoplasia)
The most common gastric neoplastic polyp is an epithelial
(raised intraepithelial neoplasia) by the World Health
Organization.
H pylori–related sporadic gastric adenomas have become rare,
accounting for <1% of all gastric polyps.
This contrasts markedly with some East Asian regions, where the
incidence of gastric cancer remains high &gastric adenomas still
constitute approximately a quarter of all gastric polyps.
similar frequency in men &women
Most commonly velvety lobulated appearance ,usually solitary
Can be found anywhere in the stomach, located more often in the
antrum.

17. Gastric Adenomas (Raised Intraepithelial
Neoplasia)
Often arise in a background of atrophy & intestinal metaplasia
typically associated with H pylori infection.
As in the colon,gastric adenomas can be viewed as part of a
sequence leading from dysplasia to carcinoma.
The larger an adenomatous polyp, the greater the probability it
contains foci of adenocarcinoma.
Synchronous adenocarcinomas, reported in up to 30% of patients
with adenomas ontaining foci of adenocarcinoma.

18. Gastric Adenomas (Raised Intraepithelial
Neoplasia)
Completely excisice all adenomas
Severity/ extent of the atrophic gastritis should be evaluated.
The same biopsy protocols&use of the OLGA or Operative Link on
Gastritis/Intestinal Metaplasia
all patients with a diagnosis of gastric adenoma need to be placed
in a surveillance program irrespective of their atrophy stage.
Eradication of H pylori followed by confirmation of the cure by
biopsy examination or urea breath test is necessary.
Gastric adenomas are neoplastic with malignant
potential, so multiple sections from each lesion must be
examined to exclude invasion.
Outside the research arena, neither special stains nor molecular
studies are necessary.

19. (A) Flat gastric adenoma with a velvety appearance in the distal
body of the stomach. (B) Gastric adenomas consist of dysplastic
columnar epithelium indistinguishable from colonic adenoma.
In resected specimens, the only clue to their gastric origin is
often a small remnant of gastric tissue from which they originate
(arrow).

20. Gastrointestinal Stromal Tumors
Neoplastic proliferations of the interstitial
cells of Cajal (or their precursors)
Arise in any segment of GIT rarely, abd/
pelvic cavity.
4000 new cases/year in US
40-60% in stomach, 2% of all gastric tums.
>in men
>in the gastric fundus.
Can be found in other regions of the
stomach.
No predisposing factors
the gastric mucosa overlying these tumors
may be

21. Gastrointestinal Stromal Tumors
Endoscopically, GISTs are wellcircumscribed submucosal
lesions; the overlying gastric mucosa is
usually normal, but it
may have an eroded or ulcerated center
Biopsy often normal so the best way is to
perform an EUS -FNA or a tru-cut needle
biopsy.
Composed by dense aggregates of
fusiform cells (spindle cells)
Two main types in the stomach (spindled
& epithelioid) with subtypes.
(presence of perinuclear vacuoles,
numbers of mitoses, necrosis&
tissue invasion) help predict their
behavior.

22. The vast majority:
<1 cm
Asymptomatic detected
incidentally during an endoscopic
Exam for other indications.
As they grow, they cause erosions
or ulcerations or compress
adjacent structures; The 2 more
common manifestations are
bleeding (occult or overt)& pain.
GIST:
Clinical approach

23. All must be considered as having
malignant potential:
Up to 50% larger GISTs (2 cm)
have metastatic disease at
presentation, usually to the liver.
A good correlation between size,
mitotic activity&clinical behavior.
Surgical resection recommended
if >2cm; ? Endoscopic enucleation
followed by surveillance is an
option for smaller.
TKIs in cases of metastasis&
surgically unresectable or
neoadjuvant after surgery.
GIST:
Clinical approach

24. IHC:
The antibody CD117, stains 95%
the remaining 5% ( typically more
epithelioid) stain with antibodies
to DOG-1 or platelet-derived
growth factor .
If none of these 3 stains, tumors
of smooth muscle (leiomyomas)
or neural (neuromas,
schwannomas) origin should be
Considered &immunostaining for
actin& S-100 should be
performed.
GIST:
Clinical approach

25. Inflammatory fibroid polyps:
Vanek tumors
What’s Your Message?

26. Extremely rare
< 0.1% of all gastric polyps.
Endoscopy: firm, solitary, sessile or pedunculated,often
ulcerated.
The histology distinctive: submucosal proliferations of spindle
cells, small vessels& conspicuous inflam infiltrate with a
predominance of eosinophils.
IHC staining suggests these polyps have a dendritic cell origin.
A recent study:70% of inflam fibroid polyps contain
gain-of-function mutations in the platelet-derived growth factor
Receptor polypeptide gene, similar to those found in
CD117-negative GISTs, suggesting a neoplastic Process.

27. Clin approach:
Most are asymptomatic.
Larger polyps cause abd pain, early satiety, anemia, GOO,
The EUS appearance may be helpful in establishing the diagnosis,
characterized by an indistinct margin, a hypoechoic
homogeneous lesion, within 2nd or 3rd layer with an intact 4th
layer.
Extremely rare, once familiar with their unique morphology they
can be diagnosed instantly.
IHC: stain for CD31.

28. Gastric NETs (carcinoid):
< 2% of gastric polyps.
Of 3 types:
Type I , 70- 80% of all gastric NETs.
They are associated with hypergastrinemia resulting
from autoimmune (corpus-restricted) atrophic gastritis
found more commonly in elderly, sp women, with atrophic
gastritis and often are associated with pernicious anemia.
These tumors are small (1 cm), confined to the oxyntic mucosa,
tend to be multiple, usually co-exist with multifocal ECL cell
hyperplasia.
Gastric NET tend to be found incidentally, often in patients
undergoing EGD as part of an evaluation for anemia.

29. Gastric NETs (carcinoid):
Type II gastric NET are associated with hypergastrinemia resulting
from a gastrin-secreting tumor.
They frequently are detected as part of the work-up for MEN-1
syndrome or for Zollinger–Ellison syndrome.
Are usually small (1 cm).
This type is the most uncommon only 5-8% of gastric NET.

30. Gastric NETs (carcinoid):Clin approach
Type I and II tumors often can be removed endoscopically.
In select patient with numerous&recurrent type I NETs, antral
resection could be a reasonable option.
Newer treatments; gastrin receptor antagonist netazepide
being investigated.
Sporadic carcinoids (type III) may present with anemia, epigastric
pain, or signs and symptoms caused by metastases, including
the rare carcinoid syndrome (characterized by cutaneous
flushing, diarrhea, bronchospasm, and cardiac valvular lesions).
Surgery followed with chemotherapy is the treatment of choice.

31. Gastric NETs (carcinoid):IHC
Neuroendocrine tumors are best diagnosed withIHC stain
(synaptophysin, chromogranin A, or CD56).
These 3 stains are essentially equivalent to highlight
neuroendocrine markers:
In addition, a Ki-67 stain should be performed to count the
percentage of proliferating cells &the grade of the tumor.

32. Overall approach:
After the histopathologic diagnosis is received, a decision
whether polypectomy is needed ;endoscopic or surgical.
Several factors should be considered when making that decision:
1. Risk of missing more serious pathology in the large polyps.
2. The presence of symptoms
3. The patient’s overall health status preferences
4. local expertise.
Biopsy-first approach is reasonable because it allows definitive
treatment to be planned according to pathology results&
after consultation with the patient.
If resection is planned, the endoscopist should be prepared to
deal with potential complications as many are highly vascular &
bleed; some (inflammatory fibroid polyps, carcinoids,GISTs) have
submucosal components that increase the risk of perforation.

33. Overall approach:
After removed or sampled, the non-affected gastric mucosa
should be inspected& a minimum of 3 biopsy specimens
from the antrum (including one from the incisura angularis)&
2 - 4 from the corpus, both the greater & lesser
curvature, should be submitted for pathologic exam, ideally in
separate containers, to see if there is H pylori infection,
atrophic gastritis, possibly with diffuse neuroendocrine
hyperplasia, or a normal mucosa.
Each of these findings would point to different management.

34. Follow-up evaluation:
No evidence-based guidelines exist.
A surveillance endoscopy on non-fundic gland polyps within 1
year is a reasonable approach to evaluate the site for recurrence
& assess for new polyps.
Follow-up evaluation after resection of polyps with high-grade
dysplasia or early cancer should be individualized, but (at least
for the first 2–3 years) short intervals (eg, 6 mo) would seem
Desirable.
Gastric carcinoids managed endoscopically (usually
type 1) should be followed up with endoscopy every 1 to 2 years.

35. SCQ1:
The most common gastric polyp in the west is:
A.Fundic gland polyps.
B.Hperplastic polyps.
C.Raised intraepithelial neoplasia.
D.Inflammatory fibroid polyps.
E.NET.

36. SCQ1:
The most common gastric polyp in the west is:
A.Fundic gland polyps.
B.Hperplastic polyps.
C.Raised intraepithelial neoplasia.
D.Inflammatory fibroid polyps.
E.NET.

37. SCQ2:
The gastric polyp that respond to a therapeutic trial is:
A.Fundic gland polyps.
B.Hperplastic polyps.
C.Raised intraepithelial neoplasia.
D.Inflammatory fibroid polyps.
E.NET.

38. SCQ2:
The gastric polyp that respond to a therapeutic trial is:
A.Fundic gland polyps.
B.Hperplastic polyps.
C.Raised intraepithelial neoplasia.
D.Inflammatory fibroid polyps.
E.NET.

39. SCQ3:
Fundic gland polyps in the west is the most common type BZ of:
A. Decreased incidence of HP infections.
B. Decreased incidence of hyperplastic polyps.
C. Increased survival of FAP patients.
D.Widespread use of antibiotics use.
E. Widespread use of PPI use.

40. SCQ3:
Fundic gland polyps in the west is the most common type BZ of:
A. Decreased incidence of HP infections.
B. Decreased incidence of hyperplastic polyps.
C. Increased survival of FAP patients.
D.Widespread use of antibiotics use.
E. Widespread use of PPI use.

41. SCQ4:
The rarest type of gastric polyps is:
A. FGPs.
B. HPPs.
C. RIN.
D.IFPs.
E. NET.

42. SCQ4:
The rarest type of gastric polyps is:
A. FGPs.
B. HPPs.
C. RIN.
D.IFPs.
E. NET.

43. SCQ5:
IFP is usually diagnosed on:
A. OGD.
B. Barium meal study.
C. Histopathology.
D.EUS.
E. PET scan.

44. SCQ5:
IFP is usually diagnosed on:
A. OGD.
B. Barium meal study.
C. Histopathology.
D.EUS.
E. PET scan.

45. SCQ6:
IFP has a characteristic appearance on:
A. OGD.
B. EUS.
C. Barium.
D.CT.
E. PET scan.

46. SCQ6:
IFP has a characteristic appearance on:
A. OGD.
B. EUS.
C. Barium.
D.CT.
E. PET scan.

47. SCQ7:
The finding of FGPs & ampullary polyp should indicate:
A. OGD.
B. EUS.
C. Barium.
D.CT.
E. Colonoscopy.

48. SCQ7:
The finding of FGPs & ampullary polyp should indicate:
A. OGD.
B. EUS.
C. Barium.
D.CT.
E. Colonoscopy.

49. SCQ8:
The finding of numerous, large or irregular shaped FGPs should
raise the possibility of:
A. FAP.
B. HNPCC.
C. PJS.
D.JPS.
E. NETs.

50. SCQ8:
The finding of numerous, large or irregular shaped FGPs should
raise the possibility of:
A. FAP.
B. HNPCC.
C. PJS.
D.JPS.
E. NETs.

51. SCQ9:
The following gastric polyps are associated with gastric atrophy
except:
A. FGP.
B. HPP.
C. RIN.
D.IFP.
E. NETs.

52. SCQ9:
The following gastric polyps are associated with gastric atrophy
except:
A. FGP.
B. HPP.
C. RIN.
D.IFP.
E. NETs.

53. SCQ10:
The MOST common gastric NET is:
A. Type 1.
B. Type 2.
C. Type 3.
D. All Equal.
E. None .

54. SCQ10:
The MOST common gastric NET is:
A. Type 1.
B. Type 2.
C. Type 3.
D. All Equal.
E. None .

55. SCQ11:
The NET with worst prognosis is:
A. Type 1.
B. Type 2.
C. Type 3 sporadic .
D. All Equal.
E. None.

56. SCQ12:
The NET with worst prognosis is:
A. Type 1.
B. Type 2.
C. Type 3 sporadic .
D. All Equal.
E. None.

57. SCQ13:
The NET type that can respond to netazepide include:
A. Type 1.
B. Type 2.
C. Type 3 sporadic .
D. A&B.
E. None.

58. SCQ13:
The NET type that can respond to netazepide include:
A. Type 1.
B. Type 2.
C. Type 3 sporadic .
D. A&B.
E. None.

59. SCQ14:
The gastric GIST that doesn't’t stain with the usual GIST –specific
stains should raise the possibility of all except:
A. Leimymoma.
B. Neuroma.
C. Shwanoma.
D. Epiotheloid type.
E. EGC.

60. SCQ14:
The gastric GIST that doesn't’t stain with the usual GIST–specific
stains should raise the possibility of all except:
A. Leimymoma.
B. Neuroma.
C. Shwanoma.
D. Epitheloid type.
E.None.

61. SCQ15:
The best diagnostic approach to gastric GIST is:
A. EUS-FNA.
B.EUS- Truecut needle biopsy.
C. OGD biopsy.
D. None.
E.All.

62. SCQ15:
The best diagnostic approach to gastric GIST is:
A. EUS-FNA.
B.EUS- Truecut needle biopsy.
C. OGD biopsy.
D. None.
E.All.