Mistakes in ... 2021 - 29

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Mistakes in... 2021
low-incidence countries suggesting an annual
gastric cancer risk with CAG and/or GIM of
0.1-0.25%,10
while a recent meta-analysis
estimated an annual progression risk of 0.5%.11
Mistake 9 Not considering polyposis
syndromes
Management of polyposis syndromes is
challenging and recent guidance is available from
the ESGE on this topic.20
With regard to gastric
polyps, the finding of numerous polyps (i.e. ≥20)
in a patient younger than 40 years of age, should
raise the possibility that they have a polyposis
syndrome.
FGPs are common in patients who have
familial adenomatous polyposis (FAP). In this
scenario there are typically multiple FGPs present
and they are often seen to 'carpet' the body of
the stomach. There is no clear guidance on
differentiating sporadic FGPs from FAP-associated
FGPs; however, as discussed, the presence of
dysplasia should cause suspicion of FAP. When
gastric polyps are associated with duodenal
adenomas then a familial polyposis syndrome
should also be considered and colonoscopy
advised if not already undertaken. Importantly,
in this scenario the use of a side-viewing scope
(duodenoscope) should be considered in order
to visualise the Ampulla of Vater due to an
association with neoplastic ampullary lesions.
Hamartomatous polyps are rare in the
stomach and they include polyps related to
Peutz-Jegher's syndrome, Cowden's disease and
juvenile polyposis. These rare polyps should all
be resected if they are >1cm and patients enrolled
into a dedicated surveillance program under the
care of a centre that has adequate expertise.1
Mistake 10 Forgetting about submucosal
lesions
Although the vast majority of gastric polyps are
epithelial in origin, it should not be forgotten that
submucosal lesions occur in the stomach. These
lesions are rare and typically found incidentally,
they should be considered if the overlying mucosa
is normal, and there may be central ulceration
(e.g. gastrointestinal stromal tumours [GISTs]).
Submucosal lesions tend to be small (<1cm),
but as they grow and lead to ulceration of the
overlying mucosa they can present with bleeding
and pain. A forceps biopsy of these lesions is often
unreliable, as the mucosa tends to slide over the
submucosal lesion, and the forceps often do
not sample the tissue deep enough to make a
histological diagnosis.
If there is clinical suspicion of a submucosal
lesion, the best modality for diagnosis is
endoscopic ultrasound (EUS) and fine-needle
aspiration (FNA), although other techniques such
as submucosal tunnelling and full-thickness
resection are options.
Other rarer submucosal lesions include
neuroendocrine tumours. These lesions require
adequate characterisation of their type and stage,
and their management should be undetaken
within a neuroendocrine tumour multidisciplinary
team.1
Inflammatory fibroid polyps originate from
the submucosa, they represent <0.1% of gastric
polyps and are associated with CAG, but they
are generally not considered to have neoplastic
potential.1
References
1. Goddard AF, Badreldin R, Pritchard DM, et al. The
management of gastric polyps. Gut 2010; 59: 1270-1276.
2. Carmack SW, Genta RM, Schuler CM, et al. The current
spectrum of gastric polyps: A 1-year national study of
over 120,000 patients. Am J Gastroenterol 2009; 104:
1524-1532.
3. el-Zimaity HM, Jackson FW and Graham DY. Fundic
gland polyps developing during omeprazole therapy.
Am J Gastroenterol 1997; 92: 1858-1860.
4. Morais DJ, Yamanaka A, Zeitune JMR, et al. Gastric
polyps: A retrospective analysis of 26,000 digestive
endoscopies. Arq Gastroenterol 2007; 44: 14-17.
5. Banks M, et al. British Society of Gastroenterology
guidelines on the diagnosis and management of
patients at risk of gastric adenocarcinoma. Gut 2019;
68: 1545-1575.
6. Bisschops R, et al. Performance measures for upper
gastrointestinal endoscopy: A European Society of
Gastrointestinal Endoscopy quality improvement
initiative. United Eur Gastroenterol J 2016; 4: 629-656.
7. Park JM, et al. Longer observation time increases
proportion of neoplasms detected by
esophagogastroduodenoscopy. Gastroenterology
2017; 153: 460-469.e1.
8. Participants in the Paris Workshop. The Paris
endoscopic classification of superficial neoplastic
lesions: esophagus, stomach, and colon: November
30 to December 1, 2002. Gastrointest Endosc 2003; 58
(6 Suppl): S3-S43.
9. Endoscopic Classification Review Group. Update on
the Paris classification of superficial neoplastic
lesions in the digestive tract. Endoscopy 2005; 37:
570-578.
10. Colling C, Asztalos I, Buchner AM, et al. Mo2037
Narrow-band imaging classification system for gastric
polyps may reduce the need for biopsies. Gastrointest
Endosc 2017; 85: AB531.
11. Shaib YH, Rugge M, Graham DY, et al. Management of
gastric polyps: An endoscopy-based approach. Clin
Gastroenterol Hepatol 2013; 11: 1374-1384.
12. Muehldorfer SM, Stolte M, Martus P, et al. Diagnostic
accuracy of forceps biopsy versus polypectomy for
gastric polyps: A prospective multicentre study. Gut
2002; 50: 465-470.
13. Lloyd IE, et al. A clinicopathologic evaluation of
incidental fundic gland polyps with dysplasia:
implications for clinical management. Am J
Gastroenterol 2017; 112: 1094-1102.
14. Zea-Iriarte WL, et al. Carcinoma in gastric
hyperplastic polyps. A phenotypic study. Dig Dis Sci
1996; 41; 377-386.
15. Parikh M, Kelley B, Rendon G, et al. Intermittent
gastric outlet obstruction caused by a prolapsing
antral gastric polyp. World J Gastrointest Oncol 2010;
2: 242.
16. Rugge M, et al. Gastric epithelial dysplasia in the
natural history of gastric cancer: A multicenter
prospective follow-up study. Gastroenterol Off J Am
Gastroenterol Assoc 1994; 107: 1288-1296.
17. Sung, JK. Diagnosis and management of
gastric dysplasia. Korean J Intern Med 2016;
31: 201-209.
18. Wang L, Huang W, Du J, et al. Diagnostic yield of the
light blue crest sign in gastric intestinal metaplasia: A
meta-analysis. PLoS One 2014; 9: e92874.
19. Kono S, et al. Can endoscopic atrophy predict
histological atrophy? Historical study in United
Kingdom and Japan. World J Gastroenterol 2015; 21:
13113-13123.
20. Van Leerdam ME, et al. Endoscopic management of
polyposis syndromes: European Society of
Gastrointestinal Endoscopy (ESGE) Guideline.
Endoscopy 2019; 51: 877-895.
Your gastric polyps briefing
Online courses
* Gastric polyps [https://ueg.eu/p/109].
* Hereditary gastrointestinal polyposis syndromes
[https://ueg.eu/p/108].
UEG Week
* " Gastric polyps and polyposis: Help! " session
at UEG Week 2019
[https://ueg.eu/library/session/
gastric-polyps-and-polyposis-help/156/2200].
* " Clinical presentation and endoscopic assessment
of gastric lesions " session at UEG Week 2019
[https://ueg.eu/library/session/
gastric-polyps-and-submucosal-lesions/156/2123]
* " Endoscopy meets pathology: Polyps and
polyposis syndromes in the upper GI tract " at
UEG Week 2016 [https://ueg.eu/library/session/
endoscopy-meets-pathology-polyps-and-polyposissyndromes-in-the-upper-gi-tract/144/1606].
*
" Gastric polyps: Diagnostic and therapeutic
approach " session at UEG Week 2016
[https://ueg.eu/library/session/
gastric-polyps-diagnostic-and-therapeuticapproach/144/1567].
Standards
and Guidelines
* Banks M, et al. British Society of Gastroenterology
guidelines on the diagnosis and management of
patients at risk of gastric adenocarcinoma. Gut 2019;
68: 1545-1575.
* Van Leerdam ME, et al. Endoscopic management of
polyposis syndromes: European Society of
Gastrointestinal Endoscopy (ESGE) Guideline.
Endoscopy 2019; 51: 877-895.
17
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