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

Approach to Gastric Polyps Found at Endoscopy

Because most polyps are found incidentally during upper endoscopies, it is crucial that the endoscopist be prepared to acquire as much information as possible during the procedure to help with the future management of the polyp.

If the appearance strongly suggests fundic gland polyps, biopsy specimens from 1 or more polyps should be taken; polyps larger than 1 cm should be resected. In the setting of fundic gland polyps special attention should be given to atypical-looking lesions, all of which should undergo a biopsy examination because they may represent other, more clinically relevant, lesions. If the appearance is not suggestive of fundic gland polyps, the endoscopist should consider complete removal of all polyps that measure 1 cm or more; if not removed such polyps should be adequately sampled. In the case of larger polyps, after the histopathologic diagnosis is received, a decision needs to be made regarding whether polypectomy is needed and, if it is, should it be endoscopic or surgical. Several factors should be considered when making that decision: (1) risk of missing more serious pathology in the large polyps,[81] (2) the presence of symptoms, (3) the patient's overall health status and preferences, and (4) local expertise. Considering that many endoscopists are not experienced with the resection of large polyps and the risk of complications is not insignificant, the biopsy-first approach is reasonable because it allows definitive treatment to be planned according to pathology results and after consultation with the patient. If resection is planned, the endoscopist should be prepared to deal with potential complications. Many of these lesions are highly vascular and tend to bleed; some (inflammatory fibroid polyps, carcinoids, and GISTs) have submucosal components that increase the risk of perforation.

The conscientious endoscopist should be guided by the principle that no polyp is an island unto itself. Thus, after polyps are removed or sampled, the nonaffected gastric mucosa should be inspected and a minimum of 3 biopsy specimens from the antrum (including one from the incisura angularis) and 2 to 4 from the corpus, sampling both the greater and lesser curvature, should be submitted for pathologic examination, ideally in separate containers. Putting them into separate containers makes possible a more precise topographic definition of any abnormalities. The information so acquired will allow determining, for example, whether the patient has H pylori infection, atrophic gastritis, possibly with diffuse neuroendocrine hyperplasia, or a normal mucosa. Each of these findings would point to different management directions.

Follow-up Evaluation

There is a dearth of data on both the short- and the long-term follow-up evaluation of gastric polyps; therefore, no evidence-based guidelines exist.[82] A surveillance endoscopy on nonfundic gland polyps within 1 year is a reasonable approach to evaluate the site for recurrence and to 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.[83] Gastric carcinoids managed endoscopically (usually type 1) should be followed up with endoscopy every 1 to 2 years.

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