Abstract: snare. Then, it was removed by piecemeal

Abstract:

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. Ultrasound shows 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 by complete resolution of all symptoms.

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Introduction:

Gastric polyps are found in
approximately 1%–6.35% of endoscopies (1). Most of these
cases are asymptomatic; however large 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 syndromatic hamartomatous
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 hyperplastic polyps 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 168 U/L, AST 137 U/L. And hyperbilirubenemia ; Total bilirubin  9 mg/dl, and direct bilirubin was 7 mg/dl.

Other investigations revealed: Amylase 1300 U/L, Lipase 650 U/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 diagnosed as 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 pylorus
to 2nd part of duodenum where a large pedunculated polyp partially
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 stomach

Figure
2: Extraction of polyp and hemoclip insertion

 

 

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 hamartomatous polyps 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
muscularis mucosa 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 syndromic hamaromatous
polyposis.