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Original report |
1
Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
2
Present address: Department of Radiology, University of Pittsburgh Medical
Center, 200 Lothrop St., Pittsburgh, PA 15213.
3
Department of Pathology and Medicine, Hospital of the University of
Pennsylvania, Philadelphia, PA 19104.
Received April 3, 2000;
accepted after revision May 1, 2000.
Address correspondence to M. S. Levine.
Abstract
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CONCLUSION. Giant hyperplastic polyps in the stomach may be manifested by distinctive findings on double-contrast barium studies, appearing as polypoid lesions with multiple lobulated components that form a conglomerate mass. Nevertheless, endoscopy and biopsy are required to rule out a polypoid carcinoma as the cause of these findings.
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Hyperplastic polyps in the stomach typically appear on double-contrast upper gastrointestinal examinations as smooth rounded nodules less than 1 cm in diameter [2, 3, 6]. Many patients have multiple polyps that tend to be clustered in the gastric fundus or body [2]. The radiographic appearance of these hyperplastic polyps is so characteristic that histologic confirmation is unnecessary when multiple small rounded polyps are found on double-contrast studies [7].
Occasionally, however, hyperplastic polyps may appear on barium studies as lobulated or pedunculated lesions as large as 2-6 cm [8, 9]. Rarely, hyperplastic polyps that are unusually large and lobulated can even be mistaken for polypoid gastric carcinoma on radiography [8, 9]. We encountered several patients with giant hyperplastic polyps in the stomach that had a similar appearance on double-contrast upper gastrointestinal examinations. Therefore, we performed a retrospective study of all pathologically proven cases at our hospital over a 10-year period to reassess the radiographic findings of giant hyperplastic polyps in the stomach.
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In all patients, the double-contrast upper gastrointestinal examinations were reviewed to determine the size, location, and morphologic features of these lesions. When additional gastric polyps were present, the number, size, location, and morphologic features of these polyps were also assessed. Medical records were reviewed to determine the clinical presentation and treatment. Endoscopic and pathologic records were also reviewed to determine the histopathologic findings.
A computerized search of our radiology database during the same period revealed 257 additional patients with typical hyperplastic polyps smaller than 1 cm on double-contrast studies in whom no endoscopic or pathologic correlation was available. Presumably, endoscopy was not performed in these patients because the radiographic findings were characteristic of hyperplastic polyps. If, for the purposes of this analysis, all of these patients had hyperplastic polyps, giant hyperplastic polyps constituted only 2% (7/286) of all hyperplastic polyps found in the stomach on double-contrast studies during this period.
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Radiographic Findings
The mean diameter of the giant hyperplastic polyps in the seven patients
was 4.7 cm (range, 3-10 cm). Five polyps were located in the gastric antrum,
one in the body, and one at the junction of the antrum and body. Six (86%) of
the seven giant hyperplastic polyps appeared on double-contrast upper
gastrointestinal examinations as multilobulated masses with trapping of barium
in the interstices between lobules, producing distinctive radiographic
findings (Figs.
1,2,3).
The largest lesion was a 10-cm mass involving the gastric antrum and body
(Fig. 2). Two of these lesions
originated in the distal antrum and had prolapsed through the pylorus,
appearing as multilobulated masses at the base of the duodenal bulb
(Fig. 3). The remaining patient
had a smooth, ovoid, and slightly lobulated mass in the gastric antrum
(Fig. 4).
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Three of the seven patients with giant hyperplastic polyps had additional gastric polyps; two had multiple smooth rounded polyps as large as 1 cm in size in the gastric antrum and body (Fig. 2). In both patients, the other satellite lesions had typical radiographic features of hyperplastic polyps. The remaining patient had two other sessile polyps that were 1 cm and 2 cm in size in the gastric body.
Endoscopic and Pathologic Findings
In all seven patients with giant hyperplastic polyps, endoscopy revealed
mass lesions in the stomach that corresponded in size and location to the
lesions seen on the barium studies. Endoscopic biopsy specimens from these
lesions revealed typical histopathologic findings of hyperplastic polyps in
all seven patients, with reactive atypia in one. Endoscopic biopsy specimens
from the surrounding mucosa revealed findings of chronic atrophic gastritis in
four patients; one of those four also had Helicobacter pylori
gastritis. In two patients with multiple small satellite polyps, endoscopic
biopsy specimens from these lesions also revealed typical histopathologic
findings of hyperplastic polyps. In a third patient with two satellite polyps,
there was no mention in the endoscopic reports that biopsy specimens had been
obtained from these smaller lesions.
The giant hyperplastic polyps were removed at surgery in two patients, including a 10-cm polypoid lesion involving the gastric antrum and body. One of these patients had a surgical polypectomy, and the other had a partial gastrectomy with roux-en-Y reconstruction. In both patients, the surgical specimens confirmed the presence of giant hyperplastic polyps. Of the remaining five patients in whom these giant hyperplastic polyps were not removed, two were doing well during follow-up periods of 1 year and 8 months, respectively. No follow-up data were available for the other three patients.
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In our study of seven patients with giant hyperplastic polyps in the stomach, the average size of the lesions was 4.7 cm, and one lesion was 10 cm. Although most patients with hyperplastic polyps have multiple polyps that tend to be located in the gastric fundus or body [2], the majority of giant hyperplastic polyps in our series occurred as solitary lesions, and all but one involved the gastric antrum. In six patients (86%), these giant hyperplastic polyps appeared as polypoid lesions with multiple lobulated components that formed a conglomerate mass, producing distinctive radiographic findings (Figs. 1,2,3). Although the pathophysiology of these giant hyperplastic polyps is uncertain, some lesions may develop from a focal cluster of small hyperplastic polyps that coalesced as they enlarged, resulting in the development of a conglomerate mass. Whatever the explanation, these lesions have such a characteristic appearance on double-contrast barium studies that the possibility of a giant hyperplastic polyp should be suspected on the basis of the radiographic findings. Nevertheless, giant hyperplastic polyps cannot be differentiated with certainty from polypoid carcinomas or other malignant lesions in the stomach; therefore, endoscopy and biopsy are required for a definitive diagnosis.
In two of our patients with giant hyperplastic polyps that originated in the distal antrum, the bulk of the lesions had prolapsed through the pylorus, appearing as large multilobulated masses at the base of the duodenal bulb (Fig. 3). In both patients, the origin of these lesions in the distal antrum was suggested by their location in the duodenum, which was contiguous with the pylorus. In a previous report, large hyperplastic polyps in the antrum that prolapsed through the pylorus were described as an unusual cause of mass lesions at the base of the duodenal bulb on barium studies [8]. Although neither of our patients had obstructive symptoms, prolapsed hyperplastic polyps in the duodenum have also been recognized as a rare cause of gastric outlet obstruction [8].
In our study, giant hyperplastic polyps in the stomach constituted 24% (7/29) of all pathologically proven hyperplastic polyps seen on double-contrast upper gastrointestinal examinations. However, this figure is misleading because patients were more likely to undergo endoscopy and biopsy when hyperplastic polyps had an atypical appearance on barium studies. During the same period, 257 additional patients had typical findings of hyperplastic polyps (i.e., smooth, rounded, sessile polyps <1 cm) on double-contrast studies, so endoscopy and biopsy were not performed on these individuals. Although the histologic nature of the polyps in these 257 patients remains unproven, most of these lesions were undoubtedly hyperplastic polyps. When these patients are included, giant hyperplastic polyps constituted only 2% (7/286) of all hyperplastic polyps found in the stomach on double-contrast studies.
Most hyperplastic polyps in the stomach are discovered as incidental findings on barium studies or during endoscopy in patients who have no symptoms related to these lesions [2]. However, in our series, all seven patients with giant hyperplastic polyps were symptomatic, and four patients presented with upper gastrointestinal bleeding. In a previous report, patients with large hyperplastic polyps in the stomach presented with upper gastrointestinal bleeding, epigastric pain, or nausea and vomiting [8]. Therefore, patients with giant hyperplastic polyps are more likely to be symptomatic than those with typical hyperplastic polyps in the stomach.
In conclusion, giant hyperplastic polyps were found in about 2% of all patients with hyperplastic polyps on double-contrast upper gastrointestinal examinations. These giant hyperplastic polyps were manifested by distinctive radiographic findings, appearing as polypoid lesions with multiple lobulated components that formed a conglomerate mass. Therefore, the possibility of a giant hyperplastic polyp in the stomach should be considered when characteristic findings are present on barium studies. Nevertheless, endoscopy and biopsy are required to rule out polypoid gastric carcinoma as the cause of these findings.
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  S. E. Rubesin, M. S. Levine, and I. Laufer Double-Contrast Upper Gastrointestinal Radiography: A Pattern Approach for Diseases of the Stomach Radiology, January 1, 2008; 246(1): 33 - 48. [Abstract] [Full Text] [PDF]
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