Most gastric polyps have an asymptomatic presentation and are an incidental finding on upper endoscopy. Symptomatic presentations can range from anemia and bleeding up to complete gastric outlet obstruction. We present a case presented to us by jaundice, vomiting, and upper abdominal pain for one week. Ultrasoundshows a picture of acute pancreatitis and obstructive jaundice.
In gastroscopy, we found a large pedunculated gastric polyp passing through pyloric ring up to 2nd part of duodenum causing a compression on duodenal papilla. It was pulled back to stomach after grasping with a snare. Then, it was removed by piecemeal technique after injection of the pedicle with diluted adrenaline. Bleeding after snaring the pedicle was secured with injection of diluted adrenaline and a insertion of a haemoclip followed bycomplete resolution of all symptoms.Introduction:Gastric polyps are found in approximately 1%–6.35% of endoscopies (1).
Most of these cases are asymptomatic; howeverlarge polyps can be presented by bleeding, anemia, or obstructive symptoms (2). Gastric hamartomatous polyps comprise about 1% of all the stomach polyps. They can be presented solitary or as a part of a clinical syndrome (3) such as Peutz–Jeghers syndrome (PJS) and juvenile polyposis. solitary polyps are usually benign except for inverted hamartomatous polyps (GIHPs), which have a 20% of malignant transformation. In contrast, the syndromatichamartomatous polyps has a higher malignancy risk that increases with age (range: 1-33%) between 30 and 60 years (4).Gastric polyps may intussuscept to duodenum causing gastric outlet obstruction.
If the prolapsed polyp contains a functional antral mucosa over it, that mucosa may keep secreting gastrin due to being placed in the alkaline media of duodenum. In turn, this hypergastrinemia may lead to erosion of the prolapsed polyp and blood loss (5).Diagnosis is often done by endoscopy; first case treated by endoscopic treatment modalities was at 1973(6).Management of gastric polyps depends on its type; In hyperplasticpolyps conservative medical management and endoscopic surveillance of smaller polyps is preferred while polypectomy is indicated in large polyps (more than 0.
5 cm) for risk of malignant transformation(7). Case presentation: A 24 years old man was admitted to hospital due to severe persistent vomiting, fatigue, and upper abdominal pain radiating to the back for one week. This condition was followed by yellowish discolouration of sclera associated with dark colored urine and low grade fever of no specific pattern. His hemoglobin was 12 g/dL, Total Leucocytic Count: 19000 x109/L with marked neutrophilia, Platelets: 340 x109/L. Liver function tests revealed elevated aminotransferases; ALT 168U/L, AST 137 U/L. And hyperbilirubenemia ; Total bilirubin 9mg/dl, and direct bilirubin was 7 mg/dl.
Other investigations revealed: Amylase 1300 U/L, Lipase 650U/L.Abdominal ultrasound revealed bulky pancreas, dilated pancreatic duct, distended gall bladder with mud inside, dilated common bile duct and intra hepatic biliary radicles. The patient was diagnosedas a case obstructive jaundice complicated by acute pancreatitis.
Patient was referred for endoscopic retrograde cholangiopancreatography which revealed distorted anatomy of stomach and large polyp occupying the 2nd part of duodenum preventing the scope from reaching papilla. Gastroscopy was done, violaceous colored twisted pedicle passing thorough pylorusto 2nd part of duodenum where a large pedunculated polyppartially obstructing the lumen. This polyp (12×8 cm in size) was originated from stomach passing down to the 2nd part of duodenum. It was pulled back to stomach after being gently grasped with large snare (Figure 1).The biopsies taken were reported as hamartoumatous gastric polyp. It was removed using piecemeal technique after injection of the pedicle with diluted adrenaline. Blood spurting after snaring the pedicle was secured with injection of diluted adrenaline and application of a haemoclip (Figure 2). Histopathology revealed hamartomous polyp.
The patient kept NPO for 48 hrs under coverage of IV fluids, proton pump inhibitor and antibiotic (Imipenam). His symptoms were relieved, his leuocytic count and bilirubin started to decline. 10 days later, the patient was quite well, freely consumed a normal diet and had normal leucocytic count, bilirubin, ALT, AST, amylase and lipase. Screening colonoscopy was normal.
Figure 1 : Lagre gastric polyp after pulling inside stomachFigure 2: Extraction of polyp and hemoclipinsertion Discussion: In literature there is no recorded cases of such a complication of a gastric polyp; Most recorded cases of giant gastric polyps developed a picture of intermittent gastric obstruction. Meta-analysis was done in 2010 for giant gastric polyp complications; about 40 cases were reviewed and showed old age and female predominance, most of these polyps were hyperplastic (90% of cases) (8). However the recorded cases of solitary hamartomatouspolyps are more prevalent in younger age (median age 43.5) with female predominate as well (9).Hamartomatous polyps are composed of epithelial elements and bundles of smooth muscle cells. Proliferation of muscularismucosa is a classic feature. (10).
Endoscopic management is preferred for large polyps, large prolapsed polyps can be dragged into stomach for easing the polypectomy procedure, instead of performing it in bulbus, which is a narrower space than stomach(11). Multiple endoscopic techniques are used for polypectomy of hamartomatous polyps; Endoscopic mucosal resection (EMR) are preferred for sessile polyps however in pedunculated polyps electrocautery snare polypectomy is done with usage of hypertonic saline epinephrine injection, endoloops, band ligation, and endoscopic haemoclips for control of bleeding. In our case,we used the combined methods for high risk bleeding control (diluted adrenaline and haemoclip) with successful control of bleeding (12).
Larger sessile polyps have a greater propensity to bleed because of larger feeding vessels. Endoscopic ultrasound (EUS) would theoretically minimize the risk of bleed by visualizing the blood vessels at the base of the gastric polyp. Surgical interference was done only in complicated cases (13). Conclusion: Gastric hamartomatous polyps are rare condition. Large polyps may be precancerous for which endoscopic resection is preferred, screening other family members is mandatory in syndromichamaromatous polyposis.