Management of Gastric Polyps

An Endoscopy-Based Approach

Yasser H. Shaib; Massimo Rugge; David Y. Graham; Robert M. Genta

Disclosures

Clin Gastroenterol Hepatol. 2013;11(11):1374-1384. 

In This Article

Abstract and Introduction

Abstract

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.

Introduction

A gastric polyp is an abnormal growth of tissue projecting from the gastric mucosal membrane. Encountering a polyp in the stomach prompts concerns regarding its histology, cause, natural history, and whether specific therapy is required. During the past few decades, North America and much of the world have experienced a marked decrease of Helicobacter pylori–related gastroduodenal diseases; during the same period, the use of proton pump inhibitors (PPIs) has become widespread. Furthermore, the indications for esophagogastroduodenoscopy (EGD) have undergone a shift, with a greater emphasis on the evaluation of gastroesophageal reflux disease and the prevention of esophageal adenocarcinoma related to Barrett's esophagus. As a result of these new paradigms, the findings encountered at EGD have changed substantially.

In North America and the industrialized West these changes have affected both the incidence and the types of gastric polyps. The overall incidence of polyps appears to have increased, as indicated by a higher prevalence in large series.[1] There also has been a shift in the relative proportion of the different types of polyps: the clinically inconsequential fundic gland polyps have become the dominant type, while growths traditionally associated with H pylori gastritis (eg, hyperplastic and adenomatous polyps) have become less common. In contrast, in East Asian, Latin American, and possibly African populations, where H pylori infection and chronic gastritis remain common, larger proportions of gastric polyps are related to the underlying inflammatory process and are either hyperplastic or neoplastic. Despite these geographic differences, the finding of gastric polyps, particularly when numerous, will make clinicians in all regions face similar quandaries: which polyps need to be excised? Which ones and how many should be sampled for histologic evaluation? Also, what follow-up evaluation is needed?

This review attempts to provide practical answers to these questions. Although it relies largely on prevalence data derived from North American and European populations, its recommendations regarding natural history, clinical approach, and follow-up evaluation are based on the natural history of each type of polyp, which is determined largely by its histology and the gastric mucosal background on which it arises. Such features are independent of prevalence and, therefore, have universal validity.

Polyps that reveal a malignancy upon histopathologic examination lose their polyp status, irrespective of their initial endoscopic appearance, and we have excluded them from this review. Furthermore, because it is impossible to be simultaneously practical and comprehensive, we also had to neglect lesions (eg, lipomas, heterotopias, and leiomyomas) because they are unlikely to cause clinical dilemmas.

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