Mistakes in ... 2021 - 26

ueg education
Mistakes in... 2021
Mistakes in the management of gastric polyps and how to
avoid them
William Waddingham and David G. Graham
Gastric polyps are usually asymptomatic, with more than 90% found incidentally and a
prevalence of up to 6% at upper endoscopy.1,2
Fundic gland polyps (FGPs) are the gastric polyps
most frequently seen in the Western world, largely due to their long-established association with
proton pump inhibitor (PPI) usage.3
endoscopist is more likely to encounter hyperplastic polyps and adenomas, which are known to
be associated with a higher malignant potential.4
Gastric polyps are often regarded as the 'poor
relation' to their colonic counterparts and as such clinicians often feel unsure how to identify,
assess and appropriately manage these lesions. Endoscopists often lack confidence in the
endoscopic characterisation of gastric polyps, feel unsure when to biopsy polyps and, if they are
biopsying polyps, how many they should sample, and finally they are not always certain what the
longer-term management is. The British Society of Gastroenterology (BSG) guidelines provide a
useful flowchart and overview of the management of gastric polyps, and the discussion here is
based on those guidelines, guidelines from the European Society of Gastrointestinal Endoscopy
(ESGE) and 12 years of clinical experience.5,6
Mistake 1 Inadequate gastric mucosal
inspection
Detection of any lesion within the gastrointestinal
tract, including gastric polyps, is highly dependent
on the quality of mucosal inspection, and to some
degree the clinical index of suspicion. Within the
stomach, techniques to improve the mucosal
view include aspiration of fluid and debris,
insufflation to expand the gastric rugae, washing
the mucosal surface with water and the use of
mucolytics (e.g. simethicone, N-acetylcysteine)
or pronase to disperse bubbles and mucus.1
These interventions should be performed
routinely in all cases.
Both the BSG & ESGE guidelines recommend
that adequate time is taken for mucosal
inspection.5,6
Although patients and their
tolerance of upper endoscopy vary, a minimum
7-minute examination time is recommended,
with data indicating this leads to a threefold
increase in the diagnosis of gastric adenomas
and cancer.7
Mistake 2 Being unaware of the mucosal
patterns of gastric polyps
When a lesion is identified it should be
documented photographically and its morphology
described using the Paris classification (figure 1).8,9
For polyps, the description should include their
size, location and number (up to 5, greater than
5 thereafter). Optical enhancement (e.g. NBI
[Olympus], i-Scan [Pentax], FICE [Fujinon]) with or
without magnification improves characterisation
of the mucosal surface and pit patterns of polyps.
Although not in routine use, an NBI classification
Ip
Protruded
lesions
IIa or LST if larger than 10mm
Flat
A high-quality gastroscopy includes
assessment of all eight anatomical landmarks
(the upper oesophagus, gastro-oesophageal
junction [GOJ], fundus in retroflexion, body,
incisura in retroflexion, antrum, duodenal bulb,
and second part of duodenum) and high-risk
stations. For completeness, these landmarks
and any lesions detected should be documented
photographically.
© UEG Waddingham and Graham.
Cite this article as: Waddingham W and Graham DG. Mistakes in
the management of gastric polyps and how to avoid them.
UEG Education 2021; 21: 14-17.
William Waddingham and David Graham are based at University
College London Hospital and University College London.
14
lesions
IIc
Depressed
lesions
Figure 1 | The Paris classification.
David Graham is a Consultant Gastroenterologist and
Interventional Endoscopist and Clinical Lead at University
College London Hospital and an Honorary Senior Lecturerer
at Univeristy College London. William Waddingham is a
Gastroenterology Specialist Registrar and MRC Clinical Research
Training Fellow.
Images: W. Waddingham and D. Graham
Illustration: J. Shadwell
Correspondence: david.graham14@nhs.net
Conflicts of interest: The authors declare they have no conflicts of
interest in relation to this article.
Published online: April 20, 2021.
III
Mucosa
Submucosa
Muscularis propria
Muscularis mucosa
IIa+c
IIb
Isp
system has been proposed to reliably diagnose
FGPs and hyperplastic polyps (<1cm) that are
known to be low-risk polyps (figure 2).10
Polyps
that are lighter or similar in colour to the
background mucosa and with no vessels or
isolated vessels have been shown in studies to be
low-risk polyps with 94-100% accuracy.10
In Western populations, up to 77% of gastric
polyps will be FGPs (figure 2), and these are
typically numerous, small (<1cm) and
smooth, hyperaemic and sessile.2,11
FGPs occur
exclusively in the gastric corpus, and on NBI
have a honeycomb appearance with dense
Is
In countries where Helicobacter pylori infection is prevalent an

Mistakes in ... 2021

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