Small polypoid lesions of the stomach

0016-5107/82/2804-0272$02.00/0 GASTROINTESTINAL ENDOSCOPY Copyright © 1982 by the American Society for Gastrointestinal Endoscopy Spectrum Small polypoid lesions of the stomach John F. Morrissey, MD Madison, Wisconsin Gastric polyps rarely represent a serious threat to a patient. Fear that such lesions might be malignant may lead to unnecessary diagnostic procedures and to overzealous ther- apeutic measures. This presentation illustrates the value of gross endoscopic diagnosis and indicates where there is need for histological confirmation of polypoid lesions. Figure 1. This gastrocamera fiberscope photograph shows a typical benign adenomatous polyp. It has a pink color distinct from the surrounding gastric mucosa. Such lesions are rarely multiple and usually will not change significantly in size over a long period of follow-up observation. Electro- surgical polypectomy provides the most accurate diagnosis and the best treatment for this lesion. Figure 2. This gastrocamera photograph is of one of the very few cases I have seen of multiple adenomatous polyps of the stomach. Traditionally this lesion has been thought to be associated with a high rate of malignant degeneration, and radical therapy, including total gastrectomy, has been recommended. Hard data are not available. The diagnosis can be made by removal of one or more of the polyps. In some cases multiple adenomatous polyps of the stomach will be associated with familial polyposis of the colon. In the latter case, the polyps tend to be very small and to involve the duodenum. Figure 3. Multiple hyperplastic polyps are shown in this photograph. These lesions are often similar in color to the surrounding gastric mucosa, are frequently irregular in shape, and are usually covered with a small amount of thin white mucus. The diagnosis is established by removal of one of the larger polyps by snare cautery. Hyperplastic polyps are usually multiple. They account for at least 95% of all gastric polyps. The lesions are of no clinical significance and no therapy is indicated. In this case the endoscopist chose to biopsy several of the lesions rather than completely excise one of them to obtain a histological diagnosis. The patho- logical report was normal gastric mucosa. Figure 4. Biopsy is unnecessary when a small flat polypoid lesion with a central umbilication is found in the distal antrum. A gross diagnosis of pancreatic rest can be made. The example shown here is of interest because a second congenital anomaly, an incomplete antral diaphragm, is also present. I favor a conservative approach to these lesions, despite reports in the surgical literature recommending re- moval of rests in symptomatic patients. The photograph was made with an Olympus OM-2 camera and a GIF-Q fiber- scope. Figure 5. Ugly, white polypoid nodules are often seen on gastrojejunostomy stomas. These inflammatory nodules are of no clinical significance. If the resection was performed more than 10 years prior to the endoscopic examination, the 266 patient is at increased risk for malignant change in the stomal area. My approach under these circumstances would be to take multiple forceps biopsies in the area and then remove one of the polypoid nodules as a large particle biopsy. This photograph was taken with an Olympus EF fiberesophagoscope. Figure 6. This small, harmless appearing, l.5-cm polyp with shallow ulceration is one of the few examples I have encountered of a polypoid early carcinoma. The diagnosis of this lesion is best established by its total removal by snare cautery. I do not think snare cautery is definitive therapy for such a patient unless complicating illness prohibits resec- tionaI surgery. The examination was with an Olympus GFB fiberscope. Figure 7. Small submucosal tumors, such as the leiomy- oma shown here, can be mistaken for mucosal polyps. The characteristic acute angle with which the lesion meets the gastric wall, the normal mucosal covering, and the presence of bridging folds serve to reveal its true nature. When these lesions are over 2 cm in size, ulceration usually occurs, frequently followed by hemorrhage. Surgical rather than endoscopic polypectomy is advised. These lesions can as- sume a dumbbell shape with the largest part of the lesion invisible to the endoscopist. Endoscopic polypectomy may remove only part of the lesion at a significant risk of perfo- ration. Forceps biopsy can often reveal the true nature of the lesion when ulceration is present. The examination was with an Olympus XTGF-2D fiberscope and an OM-2 camera. Figure 8. This is a flat l-cm lesion with a deep central ulceration, a so-called "volcano" lesion. The gross appear- ance of this polyp is characteristic of a metastatic malig- nancy. In this case the cause was chronic myelogenous leukemia. Figure 9. This is a very unusual lesion with prominent bridging folds in a patient with metastatic breast carcinoma. In order to produce this lesion the metastasis must have been to the submucosa. The photograph was taken with an Olympus OM-2 camera through an Olympus XTGF-2D fi- berscope. Figure 10. A very rare form of multiple polyposis of the stomach secondary to Peutz-jeghers syndrome is seen in this gastrocamera fiberscope photograph. In this condition the polyps are small, irregular, and covered with fairly normal appearing mucosa. The lesions are hamartomas. One lesion must be removed by snare cautery to establish the diagnosis. Figure 11. On occasion a benign ulcer may heal and leave small pseudopolyps behind, such as the lesions seen in this gastrocamera fiberscope photograph. The only importance of these lesions is that they may be mistaken for neoplasms. Atypical ulcer scars should always be evaluated by six to 10 GASTROINTESTINAL ENDOSCOPY forceps biopsies. Figure 12. These "polyps" are to be left strictly alone. They are gastric varices. The diagnosis of varices should be con- sidered in all polypoid lesions of the fundus, and biopsies should be made only when that diagnosis can be ruled out with certainty. The examination was with the Olympus GFB- K fiberscope. My advocacy of the use of snare cautery to evaluate many of these lesions warrants a word of caution. Gastric poly- VOLUME 28, NO. 4, 1982 pectomy is technically more difficult than colonic polypec- tomy. In the colon many lesions are on stalks and small sessile lesions tent easily to permit safe polypectomy, but gastric polyps are often sessile and quite vascular. The re- covery of gastric polyps can be difficult. Moreover, the polyps must be well secured to the endoscope to ensure that they are not aspirated during removal. Gastric polypec- tomy should not be attempted by an inexperienced endos- copist. 267