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Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387

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Best Practice & Research Clinical Gastroenterology


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Evaluation and management of gastric epithelial polyps


R. Castro, MD a, *, P. Pimentel-Nunes, MD, PhD a, b, c, M. Dinis-Ribeiro, MD, PhD a, b, c
a
Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
b
CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
c
CIDES-FMUP e Faculty of Medicine of the University of Porto, Porto, Portugal

a b s t r a c t
Keywords: Gastric polyps include a wide spectrum of lesions with different histology and neoplastic potential. They
Gastric epithelial polyp are found in up to 6% of upper gastrointestinal endoscopy and are usually asymptomatic and incidentally
Upper endoscopy
diagnosed, being in the vast majority epithelial gastric polyps. Hyperplastic, fundic gland and adenomas
Hiperplastic polyp
Fundic gland polyp
are the most common types of gastric polyps and, although each type may have typical endoscopic
Gastric adenoma appearances, they all must be sampled at the initial endoscopy for histological assessment. Also, the
Gastric neuroendocrine tumour normal appearing gastric mucosa should be sampled to stage atrophic changes, rule out endoscopically
Inflammatory fibroid polyp non-visible dysplasia and to diagnose Helicobacter pylori. Polyposis syndromes that affect the stomach
Hamartomatous polyp are rare but should be taken into account. Hamartomatous polyps can be found in Juvenile polyposis,
Cowden syndrome and PeutzeJeghers syndrome. On the other hand, multiple fundic gland polyps are
present in the majority of patients with familial adenomatous polyposis. In this study we provide a
comprehensive review on the evaluation and management of gastric epithelial polyps, in this way
helping physicians to properly handle this type of lesions.
© 2017 Elsevier Ltd. All rights reserved.

Introduction with the same diameter). Intermediate forms are called semi-
pedunculated (Paris 0-Isp) and they should be managed like sessile
Do to the widespread use of upper endoscopy in the past few polyps [2,3]. Some elevated lesions such as xantomas or sub-
years we have witness an increased detection in gastric polyps that, epithelial lesions must not be considered as real polyps and will not
as mention above, are usually incidentally found. The current work be addressed in this manuscript.
is structured in a practical way in order to answer the main issues
imposed by the detection of polyps in upper endoscopy and how to
Which type of polyps can usually be found in stomach? Are there
correctly approach them.
endoscopic features to different them?

What is a gastric polyp? Hyperplastic polyps represents 30e93% of all gastric epithelial
polyps and are characterized by hyperplastic foveolae with an
In practical terms, gastric polyps can be broadly defined as inflamed stroma, generally arising in response to a chronic in-
luminal lesions projecting above the plane of the gastric mucosal flammatory environment [4,5]. They are the most frequent ones in
surface [1]. According with Paris classification, a polypoid lesion is countries where Helicobacter pylori infection is common. They can
classified as Paris 0-I if its height doubles the thickness of the be sessile or pedunculated, generally with less than 20 mm in
adjacent mucosa. Polyps can be further divided into pedunculated diameter, usually occurring as single polyps in the antrum (Fig. 1a),
(Paris 0-Ip: with a narrow base) and sessile (Paris 0-Is: base and top although they can arise as multiple lesions anywhere in the gastric
mucosa [1,35e37]. This type of gastric polyp is strongly associated
with chronic gastritis, particularly H. pylori gastritis. Hyperplastic
* Corresponding author. Gastroenterology Department, Portuguese Oncology
Institute of Porto, Rua Dr. Anto nio Bernardino de Almeida, 4200-072 Porto, gastric polyps rarely undergo neoplastic progression (1.5e2.1%) but
Portugal. Fax: þ351 225084001. are associated with an increased risk of synchronous cancer
E-mail address: rui.arrais.castro@gmail.com (R. Castro). occurring elsewhere in the gastric mucosa [6,7]. The risk of

http://dx.doi.org/10.1016/j.bpg.2017.06.001
1521-6918/© 2017 Elsevier Ltd. All rights reserved.
382 R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387

Fig. 1. a. Hyperplastic polyp typical appearance with white light endoscopy. b. The same hyperplastic polyp seen with NBI.

neoplasia in these polyps is increased when they are pedunculated sessile lesions, with or without central depression or ulceration,
and bigger than 10 mm [8]. usually located in gastric fundus and body (Fig. 4a), being associ-
Fundic gland polyps (FGP) represents 16e51% of all gastric ated with autoimmune gastritis (AIG), pernicious anaemia,
epithelial polyps and are usually multiple, small, transparent and achlorhydria and hypergastrinaemia, with the excess of gastrin
sessile, often located in gastric fundus and body (Fig. 2a) [4,5]. being produced by antral G cells [14,18,19]. Type 2 represents 5% of
Fundic gland polyps are more prevalent in Western countries with all gastric neuroendocrine tumours, sharing the same macroscopic
lower rates of H. pylori infection and higher rate of PPI therapy, features as type 1 tumours. They occur in patients with Zollinger-
being the most frequent histological type in this scenario Ellison Syndrome (ZES), usually in the background of multiple
[5,10,35e37]. They are more frequent in women than in men. endocrine neoplasia type 1 (MEN1) and are associated with gas-
Sporadic fundic gland polyps rarely presents dysplasia (<1%), trinomas that lead to hypergastrinaemia and gastric hyperacidity
however in familial adenomatous polyposis (FAP), multiple polyps [14,20]. Type 3 represents 15% of neuroendocrine gastric tumours
covering the majority of gastric mucosa can be found in 80e93% of occurring sporadically as solitary, large polyps, ranging from 20 to
patients and low grade dysplasia may be present in 44e54% of 50 mm, located anywhere in the stomach without association with
cases. However, fundic gland polyps, even in patients with FAP, hipergastrinaemia [14,15,21]. This type of gastric NET has the worst
rarely progress to cancer [9]. prognosis with the highest rate of metastases.
Gastric adenomas represents 3e26% of all gastric epithelial Hamartomatous polyps are rare in the stomach and include
polyps and are strongly associated with atrophic gastritis and in- juvenile polyps, polyps of Peutz-Jeghers and Cowden syndromes
testinal metaplasia [4,5]. Solitary, often flat or sessile, generally [38]. These lesions can be indistinguishable from hyperplastic
with less than 20 mm and frequently found in the antrum (Fig. 3a), polyps [1]. Solitary juvenile polyps develop in 2% of children and
this type of polyps are true neoplasms and precursors of gastric adolescents, are usually found in the antrum and have no malig-
cancer. Adenomas larger than 20 mm and with villous histology nant potential. Multiple juvenile gastric polyps, with predominant
have a higher risk of neoplastic progression (28e40%) [11,12]. In location in the body, can be found in 14% of patients with juvenile
fact, some of this polyps harbour malignant cells, even with benign polyposis and this condition is associated with gastric malignancy
biopsies. Also, the presence of gastric adenomas is strongly asso- in 50% of cases [22]. Peutz-Jeghers syndrome is characterized by
ciated with synchronous or metachronous gastric adenocarcinoma familial gastrointestinal hamartomatous polyposis that can be
[13]. found scattered all over the stomach in 24% of affected individual
Gastric neuroendocrine tumours (NET) arise in [23]. These polyps have malignant potential, and the average age of
enterochromaffin-like cells (ECL) and are increasingly identified at patients presenting with gastric carcinoma is estimated to be 30
endoscopy, accounting for 0.6e2% of all gastric polyps [14e17]. years [13]. Gastric harmatomatous can be found in Cowden syn-
They are classified in three different types. Type 1 represents 80% of drome but gastric malignancy is rarely associated, affecting only 1%
all gastric neuroendocrine tumours and are typically found in of patients [23].
women (50e70 years) as multiple, small (<10 mm), yellowish

Fig. 2. a. Fundic gland polyp typical appearance with white light endoscopy. b. Fundic gland polyp appearance with NBI.
R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387 383

Fig. 3. a. Gastric adenoma seen with white light endoscopy. b. Gastric adenoma seen with NBI.

Fig. 4. a. Gastric NET seen with white light endoscopy. b. Gastric NET seen with NBI.

Inflammatory fibroid polyps (IFP), also known as “Vanek tu-


mours”, are rare lesions arising in the submucosa as gastric gran-
ulomas with eosinophilic infiltration and no malignant potential Table 1
[13]. They are most common in meddle-aged women with an Summary of the main features of the different types of gastric polyps.

estimated prevalence of 0.1 % and are usually present as small Histological type Endoscopic features
(<15 mm), sessile, solitary lesions in the gastric pylorus or distal Hiperplastic polyp Location: more common in the antrum
antrum [21,24,39]. Size: generally with less than 20 mm
The main features of the different types of gastric polyps are Number: solitary (66%)/multiple (33%)
summarized in Table 1. Appearance: sessile or pedunculated.
- Small lesions: smooth surface.
- Larger lesions: superficial erosion
What is the role of virtual chromoendoscopy with narrow-band Background mucosa: inflammation, atrophic/
imaging (NBI)? chronic gastritis and intestinal metaplasia with
H. pylori infection are commonly found
Fundic gland polyp Location: fundus and body
Narrow-band imaging (NBI) is an endoscopic imaging technique Size: small (1e5 mm)
that allow enhanced visualization of mucosal microscopic structure Number: usually multiple
and microvascular patterns of the superficial mucosal layer. NBI Appearance: sessile, shiny and translucent
endoscopic appearances, especially the micro vascular patterns, can Background mucosa: typically normal
Adenoma Location: Predominantly in antrum
be useful for predicting the histopathology of gastric polypoid le-
Size: variable
sions [25]. Hyperplasic polyps, which are characterized by dilated Number: solitary (>80%)
and tortuous gastric foveoli within an inflamed and edematous Appearance: sessile or flat with velvety
stroma, generally presents a dense vascular pattern. On the other lobulated surface
hand, fundic gland polyps usually presents a more regular honey Background mucosa: chronic atrophic gastritis
with intestinal metaplasia is common
comb pattern. Irregular patterns such as fine network, core Gastric NET Location: fundus and body
vascular, corkscrew or absent patterns are more often associated (type 1 and 2) Size: usually small (10 mm)
with adenomas/dysplasia and adenocarcinoma [25,26]. In the same Number: multiple
way, NBI can be an important toll when evaluating the surrounding Appearance: yellowish sessile lesions (can
present central ulceration)
mucosa. In a recent multicentre study, the use of NBI increased
Background mucosa: type 1 is usually
sensitivity and specificity for the diagnosis of intestinal metaplasia associated with atrophic gastritis of the body
and dysplasia when compared to white light alone [27]. Regular Inflammatory Location: antrum and pre-pyloric region
ridge/tubulo-villous mucosa and regular vessels, with or without fibroid polyp Size: usually smaller than 30 mm
light blue crest, are found in intestinal metaplasia (Fig. 5). Other- Number: solitary
Appearance: firm, sessile and often ulcerated
wise irregular mucosa with irregular vessels and a complete Background mucosa: can be normal
architectural loss of the mucosal and vascular pattern are strongly
384 R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387

presence of dysplasia for which forceps biopsy usually suffices


[11]. Even when there is a high suspicion of neoplastic
polyps, dysplasia should always be confirmed by direct sampling
[29].

How many biopsies?

There is no consensus on the optimal number of biopsy


specimens necessary for the diagnosis. In the past, depending of
the size, at least 6 biopsies were recommended in suspected
malignant lesions but there is now a trend towards fewer bi-
opsies to avoid increase in submucosal fibrosis that may
complicate endoscopic removal [29]. Our suggestion is to take 2
fragments of the most representative area of the polyp, ideally
directed by NBI.

Biopsies of surrounding mucosa? When and Why?

Fig. 5. NBI typical pattern of intestinal metaplasia with regular tubule-villous mucosa As a general rule, in the presence of a polyp, biopsies should
and regular vessels.
always be taken at least from the antrum and corpus. In the
presence of hyperplastic polyps and gastric adenomas, the normal
appearing gastric mucosa should be sampled to rule out dysplasia
occurring in the background of metaplastic atrophic gastritis and
to diagnose H. pylori [6,30]. Atrophic gastritis and intestinal
metaplasia are considered gastric precancerous conditions and are
often unevenly distributed throughout the stomach. For adequate
staging and grading, at least four nontargeted biopsies of two
topographic sites (at the lesser and greater curvature, from both
the antrum and the corpus) should be taken and clearly labelled in
separate vials [31]. In gastric neuroendocrine tumours, sampling
of normal appearing gastric mucosa, alongside serum gastric
measurement, can add clues to help distinguish between the
different types [14]. Even with fundic glands polyp a normal
surrounding mucosa will be reassuring when deciding not to
survey these patients.

Which to remove?

Although complete endoscopic removal must be made when-


ever possible, initial assessment of the majority of gastric polyps
Fig. 6. NBI typical appearance of dysplasia with architectural loss of the mucosal and
vascular pattern. can be made by forceps biopsy sampling. However, for polyps
larger than 10 mm forceps biopsy is inadequate to rule out
dysplasia and carcinoma, and these lesions should always be
completely removed [32]. Although sporadic FGP have low to no
associated with dysplasia [28] (Fig. 6). From our personal experi-
malignant potential, there is no consensus about the indications
ence, a fundic gland polyp presents a regular circular mucosal
for endoscopic removal. Some expert suggest that polyps larger
pattern (similar to normal gastric body mucosa) with some regular
than 10 mm should be removed and others defend that polipec-
and thin vessels (Fig. 2b). A hyperplastic polyp presents a tubular
tomy is not required for this type of polyps, unless they are
mucosal pattern, of several shapes, with thick but regular vessels
symptomatic [11,30]. Nevertheless, it is our opinion that if larger
(Fig. 1b). On the other hand, an adenoma presents a tubular
than 10 mm then they should be removed. On the other hand, it is
mucosal pattern with some regular but thin vessels (similar to in-
well established that gastric hyperplasic polyps >5 mm and ade-
testinal metaplasia) but generally with a more irregular area of
nomas regardless the size, must be completely removed [30].
absent or distorted glands with some irregular vessels, represent-
However, it is our opinion that probably some hyperplastic polyps
ing the area of dysplasia (Fig. 3b). Neuroendocrine tumours may
with 5e10 mm may not be removed given the low risk of malig-
have several shapes but generally they have a central depressed
nant transformation particularly after H. pylori eradication and
area with absent/distorted glands with irregular vessels that pre-
given the fact that this kind of polyp have a tendency to recur. The
sent a centrifugal pattern of growing (Fig. 4b).
majority of type 1 gastric NET are managed by endoscopy and
endoscopic removal is indicated in lesions >10 mm that are
Which to biopsy? localised to the mucosa or submucosa. All type 2 NET tumours
should be removed, as there is a greater risk of lymph node
As referred above, although some polyps may have typical involvement and metastases, with endoscopic resection being
endoscopic appearances, they all must be sampled at the initial indicated for all localised lesions. In type 3 tumours, the role of
endoscopy for histological type assessment and to discard the endoscopic therapy is limited, being suggested that the decision to
R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387 385

Fig. 7. Management of gastric polyps: decision algorithm. 1Hyperplastic polyps are associated with an increased risk of synchronous cancer occurring elsewhere in the gastric
mucosa and surveillance should be offered in cases of severe metaplastic atrophic gastritis. 2Some authors defend that all type II neuroendocrine tumours should be removed
regardless da size. 3Essencial to define the limits of lesion prior or during ESD.

surgically resect these lesions should mirror the principles and any visible lesion and normal appearing mucosa must be made.
guidelines for gastric adenocarcinomas. Endoscopic submucosal After excluding dysplasia in the polyp and surrounding mucosa,
dissection (ESD) can be an option for lesions smaller than 10 mm surveillance is recommended with a single upper endoscopy at 1
but partial or total gastrectomy with local lymph node resection is year. Additionally H. pylori should be tested and treated if present.
often performed [14]. IFP rarely cause clinical symptoms, however, If no residual polyp is found after one year, further surveillance is
large lesions that cause gastric outlet obstruction should be not recommended (unless the patient presents extensive atrophy
removed. Nevertheless, given the fact that biopsies are often not or metaplasia, then upper endoscopy should be repeated at 3
diagnostic in this kind of polyp they are often completely removed years intervals) [11,31] All gastric adenomas must be removed
by endoscopic resection [33,39]. regardless the size. In case of complete resection of dysplastic
lesions or well differentiated intramucosal adenocarcinoma up to
How to remove? 20 mm, surveillance could be made with endoscopy after 3e6
months and then annually. After piecemeal resection or presence
Endoscopic resection is recommended for the treatment of of positive lateral margins without meeting criteria for surgery, an
gastric superficial neoplastic lesions that possess a very low risk of endoscopy with biopsies is recommended after 3 and 9 months
lymph node metastasis. Snaring polipectomy is the preferred and then annually [29]. Once again, additional histologic sampling
technique for endoscopic resection of Paris 0-Isp or 0-Ip gastric of any visible lesion and normal appearing mucosa must be made
lesions, hyperplastic and fundic glands polyps. Endoscopic Mucosal due to strong association with atrophic gastritis, intestinal
Resection (EMR) is an acceptable option for gastric NET or metaplasia and synchronous or metachronous adenocarcinoma
dysplastic lesions smaller than 10e15 mm with a very low proba- [5,13]. The majority of type 1 NET are managed by endoscopy. As
bility of advanced histology (type Paris 0-IIa). However, ESD is the mentioned above, lesions >10 mm should be resected either by
treatment of choice for most gastric superficial neoplastic lesions, EMR or ESD, being that lesions <10 mm can be managed through
allowing higher en bloc resection rates for larger lesions with lower annually endoscopy surveillance [14]. IFP are believed to have no
levels of recurrence [29]. malignant potential and no endoscopic follow-up is recom-
mended after initial histologic confirmation [13]. Finally, it is also
Which needs surveillance? How? important to remember that chronic atrophic gastritis, intestinal
metaplasia and dysplasia are independent risk factors for gastric
After initial endoscopy with histologic assessment of gastric adenocarcinoma and also requires surveillance. Independently of
polyps and sampling of normal appearing gastric mucosa, it is the polyp histology, when atrophic gastritis or intestinal meta-
important to define which patients need surveillance and how it plasia are present both in antrum and corpus, upper endoscopy
should be done. Surveillance by upper endoscopy is not routinely with biopsies should be repeated at every three years. Patients
recommended for sporadic FGP without dysplasia once progres- with low grade dysplasia in the absence of defined lesion should
sion to gastric cancer is rare. Whoever, in young patients with receive follow-up within 1 year after diagnosis. For patients with
numerous polyps and where biopsies demonstrate dysplasia, FAP high grade dysplasia in the absence of defined lesions, immediate
should be considered and excluded with colonoscopy. If this endoscopic reassessment, ideally with chromoendoscopy, with
diagnosis is confirmed, upper endoscopy at every two years extensive biopsy sampling and surveillance at 6 month to 1 year
should be performed [11,34]. As previously referred, in the pres- intervals is indicated [31].
ence of hyperplastic polyps, additional histological assessment of
386 R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387

Conflict of interest
Pratice points
None.
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