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Management of Gastric Polyps: An Endoscopy-Based Approach

Published:April 12, 2013DOI:https://doi.org/10.1016/j.cgh.2013.03.019
      The endoscopic finding of a gastric polyp and the histopathologic report that follows may leave clinicians with questions that have not been addressed in formal guidelines: do all polyps need to be excised, or can they just be sampled for biopsy? If so, which ones and how many should be sampled? What follow-up evaluation is needed, if any? This review relies on the existing literature and our collective experience to provide practical answers to these questions. Fundic gland polyps, now the most frequent gastric polyps in Western countries because of widespread use of proton pump inhibitors, and hyperplastic polyps, the second most common polyps notable for their association with gastritis and their low but important potential for harboring dysplastic or neoplastic foci, are discussed in greater detail. Adenomas have had their name changed to raised intraepithelial neoplasia and are decreasing in parallel with Helicobacter pylori infection; however, they do retain their importance as harbingers of gastric cancer, particularly in East Asia. Gastrointestinal stromal tumors have low incidence and no known associations, but their malignant potential is high; early diagnosis and proper management are crucial. Although rare and benign, inflammatory fibroid polyps need to recognized, particularly by pathologists, to avoid misdiagnosis. Gastric neuroendocrine tumors (carcinoids) are important because of their association with either atrophic gastritis or the multiple endocrine neoplasia syndromes; those that do not arise in these backgrounds have high malignant potential and require aggressive management. The review concludes with some practical suggestions on how to approach gastric polyps detected at endoscopy.

      Keywords

      Abbreviations used in this paper:

      ECL (enterochromaffin-like), EGD (esophagogastroduodenoscopy), GIST (gastrointestinal stromal tumors), OLGA (Operative Link for Gastritis Assessment), PPI (proton pump inhibitor)
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      References

        • Carmack S.W.
        • Genta R.M.
        • Schuler C.M.
        • et al.
        The current spectrum of gastric polyps: a 1-year national study of over 120,000 patients.
        Am J Gastroenterol. 2009; 104: 1524-1532
        • Omori T.
        • Kamiya Y.
        • Tahara T.
        • et al.
        Correlation between magnifying narrow band imaging and histopathology in gastric protruding/or polypoid lesions: a pilot feasibility trial.
        BMC Gastroenterol. 2012; 12: 17
        • Elster K.
        Histologic classification of gastric polyps.
        Curr Top Pathol. 1976; 63: 77-93
        • el-Zimaity H.M.
        • Jackson F.W.
        • Graham D.Y.
        Fundic gland polyps developing during omeprazole therapy.
        Am J Gastroenterol. 1997; 92: 1858-1860
        • Raghunath A.S.
        • O'Morain C.
        • McLoughlin R.C.
        Review article: the long-term use of proton-pump inhibitors.
        Aliment Pharmacol Ther. 2005; 22: 55-63
        • Carmack S.W.
        • Genta R.M.
        • Graham D.Y.
        • et al.
        Management of gastric polyps: a pathology-based guide for gastroenterologists.
        Nat Rev Gastroenterol Hepatol. 2009; 6: 331-341
        • Bertoni G.
        • Sassatelli R.
        • Nigrisoli E.
        • et al.
        Dysplastic changes in gastric fundic gland polyps of patients with familial adenomatous polyposis.
        Ital J Gastroenterol Hepatol. 1999; 31: 192-197
        • Bianchi L.K.
        • Burke C.A.
        • Bennett A.E.
        • et al.
        Fundic gland polyp dysplasia is common in familial adenomatous polyposis.
        Clin Gastroenterol Hepatol. 2008; 6: 180-185
        • Attard T.M.
        • Cuffari C.
        • Tajouri T.
        • et al.
        Multicenter experience with upper gastrointestinal polyps in pediatric patients with familial adenomatous polyposis.
        Am J Gastroenterol. 2004; 99: 681-686
        • Domizio P.
        • Talbot I.C.
        • Spigelman A.D.
        • et al.
        Upper gastrointestinal pathology in familial adenomatous polyposis: results from a prospective study of 102 patients.
        J Clin Pathol. 1990; 43: 738-743
        • Genta R.M.
        • Schuler C.M.
        • Robiou C.I.
        • et al.
        No association between gastric fundic gland polyps and gastrointestinal neoplasia in a study of over 100,000 patients.
        Clin Gastroenterol Hepatol. 2009; 7: 849-854
        • Kim J.S.
        • Chae H.S.
        • Kim H.K.
        • et al.
        [Spontaneous resolution of multiple fundic gland polyps after cessation of treatment with omeprazole].
        Korean J Gastroenterol. 2008; 51: 305-308
        • Hongo M.
        • Fujimoto K.
        • Gastric Polyps Study Group
        Incidence and risk factor of fundic gland polyp and hyperplastic polyp in long-term proton pump inhibitor therapy: a prospective study in Japan.
        J Gastroenterol. 2010; 45: 618-624
        • Jianu C.S.
        • Fossmark R.
        • Viset T.
        • et al.
        Gastric carcinoids after long-term use of a proton pump inhibitor.
        Aliment Pharmacol Ther. 2012; 36: 644-649
        • Jianu C.S.
        • Lange O.J.
        • Viset T.
        • et al.
        Gastric neuroendocrine carcinoma after long-term use of proton pump inhibitor.
        Scand J Gastroenterol. 2012; 47: 64-67
        • Fossmark R.
        • Jianu C.S.
        • Martinsen T.C.
        • et al.
        Serum gastrin and chromogranin A levels in patients with fundic gland polyps caused by long-term proton-pump inhibition.
        Scand J Gastroenterol. 2008; 43: 20-24
        • Abraham N.S.
        Proton pump inhibitors: potential adverse effects.
        Curr Opin Gastroenterol. 2012; 28: 615-620
        • Bajaj J.S.
        • Ratliff S.M.
        • Heuman D.M.
        • et al.
        Proton pump inhibitors are associated with a high rate of serious infections in veterans with decompensated cirrhosis.
        Aliment Pharmacol Ther. 2012; 36: 866-874
        • Juel J.
        • Pareek M.
        • Jensen S.E.
        The clopidogrel-PPI interaction: an updated mini-review.
        Curr Vasc Pharmacol. 2012; (Epub ahead of print)
        • Rotramel A.
        • Poritz L.S.
        • Messaris E.
        • et al.
        PPI therapy and albumin are better predictors of recurrent Clostridium difficile colitis than choice of antibiotics.
        J Gastrointest Surg. 2012; 16: 2267-2273
        • Vakil N.
        Prescribing proton pump inhibitors: is it time to pause and rethink?.
        Drugs. 2012; 72: 437-445
        • Lau Y.T.
        • Ahmed N.N.
        Fracture risk and bone mineral density reduction associated with proton pump inhibitors.
        Pharmacotherapy. 2012; 32: 67-79
        • Dirschmid K.
        • Platz-Baudin C.
        • Stolte M.
        Why is the hyperplastic polyp a marker for the precancerous condition of the gastric mucosa?.
        Virchows Arch. 2006; 448: 80-84
        • Archimandritis A.
        • Spiliadis C.
        • Tzivras M.
        • et al.
        Gastric epithelial polyps: a retrospective endoscopic study of 12974 symptomatic patients.
        Ital J Gastroenterol. 1996; 28: 387-390
        • Abraham S.C.
        • Singh V.K.
        • Yardley J.H.
        • et al.
        Hyperplastic polyps of the stomach: associations with histologic patterns of gastritis and gastric atrophy.
        Am J Surg Pathol. 2001; 25: 500-507
        • Cerwenka H.
        • Bacher H.
        • Mischinger H.J.
        Pyloric obstruction caused by prolapse of a hyperplastic gastric polyp.
        Hepatogastroenterology. 2002; 49: 958-960
        • Chen H.W.
        • Lu C.H.
        • Shun C.T.
        • et al.
        Gastric outlet obstruction due to giant hyperplastic gastric polyps.
        J Formos Med Assoc. 2005; 104: 852-855
        • Dixon M.F.
        • O'Connor H.J.
        • Axon A.T.
        • et al.
        Reflux gastritis: distinct histopathological entity?.
        J Clin Pathol. 1986; 39: 524-530
        • Maguilnik I.
        • Neumann W.L.
        • Sonnenberg A.
        • et al.
        Reactive gastropathy is associated with inflammatory conditions throughout the gastrointestinal tract.
        Aliment Pharmacol Ther. 2012; 36: 736-743
        • Lauwers G.Y.
        • Wahl S.J.
        • Melamed J.
        • et al.
        p53 expression in precancerous gastric lesions: an immunohistochemical study of PAb 1801 monoclonal antibody on adenomatous and hyperplastic gastric polyps.
        Am J Gastroenterol. 1993; 88: 1916-1919
        • Nogueira A.M.
        • Carneiro F.
        • Seruca R.
        • et al.
        Microsatellite instability in hyperplastic and adenomatous polyps of the stomach.
        Cancer. 1999; 86: 1649-1656
        • Murakami K.
        • Mitomi H.
        • Yamashita K.
        • et al.
        p53, but not c-Ki-ras, mutation and down-regulation of p21WAF1/CIP1 and cyclin D1 are associated with malignant transformation in gastric hyperplastic polyps.
        Am J Clin Pathol. 2001; 115: 224-234
        • Yao T.
        • Kajiwara M.
        • Kuroiwa S.
        • et al.
        Malignant transformation of gastric hyperplastic polyps: alteration of phenotypes, proliferative activity, and p53 expression.
        Hum Pathol. 2002; 33: 1016-1022
        • Hattori T.
        Morphological range of hyperplastic polyps and carcinomas arising in hyperplastic polyps of the stomach.
        J Clin Pathol. 1985; 38: 622-630
        • Zea-Iriarte W.L.
        • Sekine I.
        • Itsuno M.
        • et al.
        Carcinoma in gastric hyperplastic polyps. A phenotypic study.
        Dig Dis Sci. 1996; 41: 377-386
        • Rugge M.
        • Leandro G.
        • Farinati F.
        • et al.
        Gastric epithelial dysplasia. How clinicopathologic background relates to management.
        Cancer. 1995; 76: 376-382
        • Capelle L.G.
        • de Vries A.C.
        • Haringsma J.
        • et al.
        The staging of gastritis with the OLGA system by using intestinal metaplasia as an accurate alternative for atrophic gastritis.
        Gastrointest Endosc. 2010; 71: 1150-1158
        • Rugge M.
        • Meggio A.
        • Pennelli G.
        • et al.
        Gastritis staging in clinical practice: the OLGA staging system.
        Gut. 2007; 56: 631-636
        • Dixon M.F.
        • Genta R.M.
        • Yardley J.H.
        • et al.
        Classification and grading of gastritis. The updated Sydney system. International Workshop on the Histopathology of Gastritis, Houston 1994.
        Am J Surg Pathol. 1996; 20: 1161-1181
        • Graham D.Y.
        • Nurgalieva Z.Z.
        • el-Zimaity H.M.
        • et al.
        Noninvasive versus histologic detection of gastric atrophy in a Hispanic population in North America.
        Clin Gastroenterol Hepatol. 2006; 4: 306-314
        • Vilaichone R.K.
        • Mahachai V.
        • Graham D.Y.
        Helicobacter pylori diagnosis and management.
        Gastroenterol Clin North Am. 2006; 35: 229-247
        • Suzuki S.
        • Ohkusa T.
        • Shimoi K.
        • et al.
        Disappearance of multiple hyperplastic polyps after the eradication of Helicobacter pylori.
        Gastrointest Endosc. 1997; 46: 566-568
        • Ohkusa T.
        • Takashimizu I.
        • Fujiki K.
        • et al.
        Disappearance of hyperplastic polyps in the stomach after eradication of Helicobacter pylori. A randomized, clinical trial.
        Ann Intern Med. 1998; 129: 712-715
        • Lauwers G.Y.
        • Carneiro F.
        • Graham D.Y.
        • et al.
        Gastric carcinoma.
        in: Bosman F.T. Carneiro F. Hruban R.H. WHO classification of tumors of the digestive system. 4th ed. International Agency for Research Against Cancer, Lyon2010: 48-58
        • Lauwers G.Y.
        • Srivastava A.
        Gastric preneoplastic lesions and epithelial dysplasia.
        Gastroenterol Clin North Am. 2007; 36 (vi): 813-829
        • Stolte M.
        • Sticht T.
        • Eidt S.
        • et al.
        Frequency, location, and age and sex distribution of various types of gastric polyp.
        Endoscopy. 1994; 26: 659-665
        • Nakamura T.
        • Nakano G.
        Histopathological classification and malignant change in gastric polyps.
        J Clin Pathol. 1985; 38: 754-764
        • Laxén F.
        • Sipponen P.
        • Ihamäki T.
        • et al.
        Gastric polyps; their morphological and endoscopical characteristics and relation to gastric carcinoma.
        Acta Pathol Microbiol Immunol Scand A. 1982; 90: 221-228
        • Abraham S.C.
        • Park S.J.
        • Lee J.H.
        • et al.
        Genetic alterations in gastric adenomas of intestinal and foveolar phenotypes.
        Mod Pathol. 2003; 16: 786-795
        • Rugge M.
        • Farinati F.
        • Baffa R.
        • et al.
        Gastric epithelial dysplasia in the natural history of gastric cancer: a multicenter prospective follow-up study. Interdisciplinary Group on Gastric Epithelial Dysplasia.
        Gastroenterology. 1994; 107: 1288-1296
        • Tan C.B.
        • Zhi W.
        • Shahzad G.
        • et al.
        Gastrointestinal stromal tumors: a review of case reports, diagnosis, treatment, and future directions.
        ISRN Gastroenterol. 2012; 2012: 595968
        • DeMatteo R.P.
        • Lewis J.J.
        • Leung D.
        • et al.
        Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival.
        Ann Surg. 2000; 231: 51-58
        • DeMatteo R.P.
        • Ballman K.V.
        • Antonescu C.R.
        • et al.
        Adjuvant imatinib mesylate after resection of localised, primary gastrointestinal stromal tumour: a randomised, double-blind, placebo-controlled trial.
        Lancet. 2009; 373: 1097-1104
        • DeMatteo R.P.
        Nanoneoadjuvant therapy of gastrointestinal stromal tumor (GIST).
        Ann Surg Oncol. 2009; 16: 799-800
        • Demetri G.D.
        • Benjamin R.S.
        • Blanke C.D.
        • et al.
        NCCN Task Force report: management of patients with gastrointestinal stromal tumor (GIST)–update of the NCCN clinical practice guidelines.
        J Natl Compr Canc Netw. 2007; 5: S1-S29
        • Miettinen M.
        • Lasota J.
        Gastrointestinal stromal tumors–definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis.
        Virchows Arch. 2001; 438: 1-12
        • Miettinen M.
        • Lasota J.
        Histopathology of gastrointestinal stromal tumor.
        J Surg Oncol. 2011; 104: 865-873
        • Kawanowa K.
        • Sakuma Y.
        • Sakurai S.
        • et al.
        High incidence of microscopic gastrointestinal stromal tumors in the stomach.
        Hum Pathol. 2006; 37: 1527-1535
        • Hueman M.T.
        • Schulick R.D.
        Management of gastrointestinal stromal tumors.
        Surg Clin North Am. 2008; 88 (vii): 599-614
        • Nilsson B.
        • Sjölund K.
        • Kindblom L.G.
        • et al.
        Adjuvant imatinib treatment improves recurrence-free survival in patients with high-risk gastrointestinal stromal tumours (GIST).
        Br J Cancer. 2007; 96: 1656-1658
        • Miettinen M.
        • Lasota J.
        Gastrointestinal stromal tumors: pathology and prognosis at different sites.
        Semin Diagn Pathol. 2006; 23: 70-83
        • Hasegawa T.
        • Yang P.
        • Kagawa N.
        • et al.
        CD34 expression by inflammatory fibroid polyps of the stomach.
        Mod Pathol. 1997; 10: 451-456
        • Allibone R.O.
        • Nanson J.K.
        • Anthony P.P.
        Multiple and recurrent inflammatory fibroid polyps in a Devon family (“Devon polyposis syndrome”): an update.
        Gut. 1992; 33: 1004-1005
        • Pantanowitz L.
        • Antonioli D.A.
        • Pinkus G.S.
        • et al.
        Inflammatory fibroid polyps of the gastrointestinal tract: evidence for a dendritic cell origin.
        Am J Surg Pathol. 2004; 28: 107-114
        • Schildhaus H.U.
        • Cavlar T.
        • Binot E.
        • et al.
        Inflammatory fibroid polyps harbour mutations in the platelet-derived growth factor receptor alpha (PDGFRA) gene.
        J Pathol. 2008; 216: 176-182
        • Rossi P.
        • Montuori M.
        • Balassone V.
        • et al.
        Inflammatory fibroid polyp. A case report and review of the literature.
        Ann Ital Chir. 2012; 83: 347-351
        • Matsushita M.
        • Okazaki K.
        Atypical EUS features of gastric inflammatory fibroid polyps.
        Gastrointest Endosc. 2005; 61: 637-638
        • Matsushita M.
        • Takakuwa H.
        • Nishio A.
        Characteristic endosonographic features of gastric inflammatory fibroid polyps.
        Endoscopy. 2001; 33: 729-730
        • Matsushita M.
        • Hajiro K.
        • Okazaki K.
        • et al.
        Endoscopic features of gastric inflammatory fibroid polyps.
        Am J Gastroenterol. 1996; 91: 1595-1598
        • Klöppel G.
        • Perren A.
        • Heitz P.U.
        The gastroenteropancreatic neuroendocrine cell system and its tumors: the WHO classification.
        Ann N Y Acad Sci. 2004; 1014: 13-27
        • Solcia E.
        • Arnold R.
        • Capella C.
        • et al.
        Neuroendocrine neoplasms of the stomach.
        in: Bosman F.T. Carneiro F. Hruban R.H. WHO classification of tumors of the digestive system. 4th ed. International Agency for Research Against Cancer, Lyon2010: 64-68
        • Solcia E.
        • Rindi G.
        • Paolotti D.
        • et al.
        Natural history, clinicopathologic classification and prognosis of gastric ECL cell tumors.
        Yale J Biol Med. 1998; 71: 285-290
        • Rindi G.
        • Bordi C.
        • Rappel S.
        • et al.
        Gastric carcinoids and neuroendocrine carcinomas: pathogenesis, pathology, and behavior.
        World J Surg. 1996; 20: 168-172
        • Solcia E.
        • Fiocca R.
        • Villani L.
        • et al.
        Morphology and pathogenesis of endocrine hyperplasias, precarcinoid lesions, and carcinoids arising in chronic atrophic gastritis.
        Scand J Gastroenterol Suppl. 1991; 180: 146-159
        • von Rosenvinge E.C.
        • Wank S.A.
        • Lim R.M.
        Gastric masses in multiple endocrine neoplasia type I-associated Zollinger-Ellison syndrome.
        Gastroenterology. 2009; 137 (, 537): 1222
        • Kulke M.H.
        • Anthony L.B.
        • Bushnell D.L.
        • et al.
        NANETS treatment guidelines: well-differentiated neuroendocrine tumors of the stomach and pancreas.
        Pancreas. 2010; 39: 735-752
        • Kulke M.H.
        • Chan J.A.
        • Meyerhardt J.A.
        • et al.
        A prospective phase II study of 2-methoxyestradiol administered in combination with bevacizumab in patients with metastatic carcinoid tumors.
        Cancer Chemother Pharmacol. 2011; 68: 293-300
        • Rindi G.
        • Azzoni C.
        • La Rosa S.
        • et al.
        ECL cell tumor and poorly differentiated endocrine carcinoma of the stomach: prognostic evaluation by pathological analysis.
        Gastroenterology. 1999; 116: 532-542
        • Borch K.
        • Ahrén B.
        • Ahlman H.
        • et al.
        Gastric carcinoids: biologic behavior and prognosis after differentiated treatment in relation to type.
        Ann Surg. 2005; 242: 64-73
        • Fossmark R.
        • Sørdal O.
        • Jianu C.S.
        • et al.
        Treatment of gastric carcinoids type 1 with the gastrin receptor antagonist netazepide (YF476) results in regression of tumours and normalisation of serum chromogranin A.
        Aliment Pharmacol Ther. 2012; 36: 1067-1075
        • Muehldorfer S.M.
        • Stolte M.
        • Martus P.
        • et al.
        Diagnostic accuracy of forceps biopsy versus polypectomy for gastric polyps: a prospective multicentre study.
        Gut. 2002; 50: 465-470
        • Dinis-Ribeiro M.
        • Areia M.
        • de Vries A.C.
        • et al.
        Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED).
        Endoscopy. 2012; 44: 74-94
        • Rugge M.
        • Cassaro M.
        • Di Mario F.
        • et al.
        The long term outcome of gastric non-invasive neoplasia.
        Gut. 2003; 52: 1111-1116