Hyperplastic gastric polyp causing progressive gastric outlet obstruction

Hyperplastic polyps represent 75 to 90% of gastric polypoid lesions. The manifestations of these unique gastric neoplasms vary, including abdominal pain, nausea, and vomiting or gastrointestinal bleeding. The vast majority of these lesions are small, asymptomatic, and found incidentally on radiologic evaluation or endoscopic examination of the upper gastrointestinal tract. Herein we describe a large, benign, pedunculated hyperplastic polyp that led to progressive gastric outlet obstruction. In addition, we provide an overview of gastric polyps and a review of the literature. Excision of gastric polyps by endoscopic or surgical means is recommended as prudent treatment to eliminate occurrence of malignant foci.     

Which colonic polyps should be excised endoscopically?

A review of 464 consecutive polypoid lesions of the colon reveals that virtually all pedunculated polyps and over 80% of 218 sessile polyps were removed colonoscopically. Although size or location of the lesions occasionally precludes colonoscopic excision, the endoscopic appearance of a sessile polyp is the most important factor in deciding upon the method of excision. In gneeral, smooth, soft, nonulcerated sessile lesions of all sizes were excised endoscopically, while approximately half of the larger (2-6 cm) firm, irregular-surfaced, benign sessile lesions, and all ulcerated or malignant sessile lesions required laparotomy for proper management. All polypoid lesions should be viewed endoscopically before deciding the method of excision, regardless of their size, location, or general appearnce by barium enema. Experience with endoscopic morphology and snare electrocautery technics was most important, since more than 85% of all polypoid lesions in this consecutive series were removed endoscopically.     

Bacillary angiomatosis associated with extensive esophageal polyposis: a new mucocutaneous manifestation of acquired immunodeficiency disease (AIDS)

Bacillary angiomatosis is a rare infection that has been associated with human immunodeficiency virus infection. The causative organism is Rochalimaea henselae and contact with cats is a risk factor. We present a case of a 37-yr-old man who had recent prolonged exposure to a cat and presented with fever, iron deficiency anemia, and guaiac-positive stools who had biopsy-proven bacillary angiomatosis skin lesions and on esophagogastroduodenoscopy had multiple, diffuse, friable, polypoid lesions in the esophagus. The histology of the esophageal polyps was identical to the skin lesions, and the polyps disappeared after treatment with erythromycin. Bacillary angiomatosis should be included in the differential diagnosis of infectious upper gastrointestinal manifestations associated with AIDS.     

Clinical evaluation of fundic gland polyps and hyperplastic polyps

We performed a retrospective review of 477 cases of fundic gland polyps compared with 562 cases of hyperplastic polyps, which were detected endoscopically during the past 8 years between January, 1989 and December, 1996. All lesions were histologically confirmed by endoscopic biopsy or the examination of polypectomy specimens. Fundic gland polyps were more prevalent in middle aged-female, and were not associated with gastric adenomas and gastric cancers. These results suggested that the background mucosa of patients with fundic gland polyp was different from that of patients with hyperplastic polyp. Fundic gland polyps in 55 patients were followed up. No change was observed in the polyps of the about half subjects, the polyps of 12 cases (21.8%) decreased in size and number or resolved completely. Cases decreased in size and number or resolved completely were much more in fundic gland polyps than hyperplastic polyps. There were no malignant transformation of fundic gland polyps. We claimed that fundic gland polyps were benign and distinct from hyperplastic polyps which had a possibility of malignant transformation.     

Response to Weisz''s and Kappauf''s critiques of the Temple longitudinal study

Because of rapid technological advances in endoscopic instrumentation, electrosurgical polypectomy and electrocoagulation has become a reality in the upper gastrointestinal tract. Twenty gastric polyps and three duodenal polyps have been removed. Six additional hyperplastic gastric polyps were electrodesiccated. Nine gastric ulcers, four duodenal ulcers, one hemorrhagic gastritis, one gastric varix and three Mallory-Weiss tears were successfully electrocoagulated. One duodenal ulcer and one Mallory-Weiss tear was unsuccessfully electrocoagulated. No morbidity nor mortality occurred as a result of electrosurgical polypectomy or electrocoagulation.     

CT evaluation of small polypoid lesions of the gallbladder

BACKGROUND/AIMS: The ability of CT to differentiate small polypoid lesions of the gallbladder was evaluated. MATERIAL AND METHODS: CT followed by cholecystectomy was performed in 20 patients with small polypoid lesions (< or = 20mm) of the gallbladder measured by preoperative ultrasonography. Detectability of the lesions on both unenhanced and enhanced CT, and the configuration and density of the polypoid lesions on enhanced CT were evaluated in comparison with histopathology. RESULTS: Unenhanced CT detected 8 of 20 polypoid lesions (40%), whereas enhanced CT detected all lesions. All the cholesterol polyp (n = 9) and hyperplastic polyp (n = 2) were not detected on unenhanced CT. Configurations of the polypoid lesions were classified into three types; pedunculated, sessile, and mass forming type. All of cholesterol polyp and hyperplastic polyp were demonstrated as pedunculated type, and adenomyomatosis (n = 2) as mass forming type in all lesions, respectively. Two of adenoma were seen as pedunculated type in one and as mass forming type in the other. Adenocarcinoma (n = 5) was depicted as sessile type in four lesions and as pedunculated type in one. The density of the lesions compared with the liver parenchyma on enhanced CT was not specific. CONCLUSIONS: The configuration of polypoid lesions depicted on enhanced CT and visualization of them on unenhanced CT are helpful in differentiating neoplastic lesions which should be resected from other benign lesions.     

Cowden's disease--a report on the first case in Korea and literature review

Cowden's disease, or multiple hamartoma syndrome, is an uncommon condition with characteristic mucocutaneous lesions associated with abnormalities of the breast, thyroid, and gastrointestinal tract. We describe a 32-year-old man with oral mucosal papillomatosis and plantar hyperkeratosis as a definite case of Cowden's disease according to the criteria proposed by Salem and Steck. The patient also had a thyroid mass and numerous gastrointestinal polyps endoscopically. Histologically the polyps were hamartomatous or hyperplastic polyps. The oral papillary lesions were fibroepithelial polyps and the thyroid mass was a follicular adenoma. We review the literature on this entity and summarize the pertinent findings. To the best of our knowledge, this is the first documented case of Cowden's disease in a Korean.     

Central nervous system (CNS) involvement in SLE. The diagnostic role of antibodies to neuronal antigens

Dysplasia in inflammatory bowel disease (IBD) is categorized as either flat or associated with a raised lesion or mass (dysplasia-associated lesion or mass [DALM]). One specific subtype of a dysplasia-associated lesion or mass consists of isolated discrete nodules or polyps that are difficult to distinguish from sporadic adenomas. Because the clinical management of these two lesions is different, we performed this study to (1) evaluate the clinical presentation, pathologic features, and natural history of polypoid dysplastic lesions and sporadic adenomas in patients with IBD and (2) determine whether there are clinical, endoscopic, or pathologic findings useful in differentiating between these two lesions. The morphologic features of 89 benign polypoid epithelial neoplasms from 59 patients with IBD (51 with ulcerative colitis, 8 with Crohn's colitis) were evaluated and correlated with the clinical, endoscopic, and follow-up data. In a separate analysis, patients were categorized arbitrarily as having (1) a probable sporadic adenoma if the polypoid epithelial neoplasm was not located within areas of histologically proven colitis, (2) a probable IBD-associated polypoid dysplasia if the lesion developed within an area of colitis, and associated flat dysplasia or an adenocarcinoma was detected during follow-up evaluation or (3) an indeterminate polyp, which was seen in the remainder of the cases. The clinical, endoscopic, and histologic data were compared among these three patient and polyp subgroups. There were 35 males and 24 females (median age, 57 years; range, 27-85 years). Median duration of disease was 10 years. Forty-nine percent of the patients had pancolitis; 66% had histologically active disease at the time of presentation. Nearly 70% of patients had only one polyp; the majority occurred in either the left colon or the rectum (66%). Most polyps were described as a sessile nodule, whereas only 7 (7.8%) were pedunculated. Polyps ranged from 2 mm to 50 mm (median, 5 mm); most had a tubular architecture (84.3%) and contained low-grade dysplasia (64%). In addition, most polyps had mildly increased lamina propria and intraepithelial neutrophilic and mononuclear inflammation. At follow-up evaluation (40 patients; median follow-up time, 13 months; range, 1-78 months), a further neoplastic lesion developed in 20%; low-grade flat dysplasia was seen in 5 (12.5%), and adenocarcinoma developed in 3 (7.5%). However, dysplasia or adenocarcinoma did not develop in the patients who had polyps located outside of areas of histologically proven colitis. In addition, at least one more benign polypoid epithelial neoplasm developed in 15 of 40 patients (37.5%). Patients with probable IBD-associated polypoid dysplasia had a statistically significant (p < 0.05), longer disease duration than patients with probable sporadic adenoma. A statistically significant, higher proportion of polyps with tubullovillous or villous architecture, an admixture of normal and dysplastic epithelium at the surface of the polyps, and increased lamina propria mononuclear inflammation was noted in probable IBD-associated polypoid dysplastic lesions compared with those considered to be sporadic adenomas. Several clinical and pathologic features may be useful to help categorize a polypoid dysplastic lesion as a sporadic adenoma or an IBD-related neoplasm in a patient with IBD. This distinction is important because the natural history of these two lesions (as shown by the results of this study) and their subsequent management are quite different.     

Current aspects of diagnosis and therapy of nasal polyposis

Nasal polyps are tumor-like, hyperplastic swellings of the nasal mucous membranes. The histology may vary. The clinical picture shows a great heterogeneity, ranging from single polyps (so-called choanal polyps) to almost complete polypoid transformation of the mucosa in all paranasal sinuses. Nasal polyps may be associated with different inflammatory nasal diseases such as chronic rhino-sinusitis, cystic fibrosis and Kartagener's syndrome. The exact pathogenesis of nasal polyps is unknown. Several theories have been formulated over the past 20 years attributing nasal polyps to a variety of causes including allergy, genetic predisposition and inflammation. Recently, a relationship has been demonstrated between the production of cytokines and the formation and activation of inflammatory cells in the polyps. The diagnosis and surgical treatment of nasal polyposis has been decisively developed over the past decade. Current diagnostic and therapeutic concepts are presented for the treatment of nasal polyposis. Precise indications for medical and surgical treatment of nasal polyposis can be derived from an evaluation of the allergic endoscopic and radiological examinations. Glucocorticoids play a dominant role in conservative therapy. Topical application of steroids is the preferred route. Surgical therapy should not be radical. It should focus on the lateral nasal wall rather than on the healthy mucosa of the sinuses itself.     

The vascular effects of topical and intravenous alpha2-adrenoceptor agonist clonidine on canine pial microcirculation

Helicobacter pylori infection of the gastric mucosal surface was investigated in patients with hamartomatous fundic polyps or hyperplastic polyps and in patients without endoscopic evidence of disease (healthy subjects). Presence of H. pylori infection was determined by culture, histologic examination, and the endoscopic phenol red test. Adherence of H. pylori was evaluated with scanning electron microscopic examination of antral biopsy specimens. Both prevalence of H. pylori infection (P < 0.001) and H. pylori adherence (P < 0.05) were less in patients with hamartomatous fundic polyps than in healthy subjects and patients with hyperplastic polyps. However, the percentages of plasma cells in gastric mucosa that contained IgA and of gastric epithelial cells that expressed Lewis b did not differ significantly among the three groups. These findings suggest that defense mechanisms against the attachment of H. pylori other than IgA or Lewis b antigen are present in patients with hamartomarous fundic polyps.     

A prospective evaluation of the safety and efficacy of methohexital in the emergency department

OBJECTIVE: Knowledge of a possible correlation between distal polyps found at screening sigmoidoscopy and proximal colonic lesions is important for deciding whether to perform total colonoscopy or not. PATIENTS: A prospective analysis of 2439 consecutive patients with colorectal polyps. Of these, 304 were asymptomatic subjects who underwent complete colonoscopy for screening and were found to have adenomatous or hyperplastic polyps in the distal colorectum. RESULTS: Ten (15%) out of 65 patients with distal hyperplastic polyps only and 86 (36%) out of 239 with distal adenomatous polyps were found to have adenomatous polyps in the proximal colon as well (P < 0.001). The frequency of synchronous proximal adenomas in patients with small (< or = 5 mm) or large distal adenomas (> 5 mm) was comparable (37% and 35%, respectively). However, patients with small distal adenomas had significantly smaller proximal adenomas (P = 0.004) containing less villous component (P = 0.017) than those with large distal adenomas. Neither the patient's age nor the presence of multiple distal adenomas increased the prevalence of proximal adenomas. CONCLUSION: Hyperplastic polyps found on rectosigmoidoscopy do not indicate a need for a complete colorectal examination, as 15% of patients with distal hyperplastic polyps will have proximal adenomatous polyps, a figure that is comparable with that of asymptomatic patients having no distal polyps, either hyperplastic or adenomatous. When only small distal adenomas are found at screening sigmoidoscopy in asymptomatic persons the decision to do a total colonoscopy should be based on individual considerations, as in such cases only small polyps are to be expected in the proximal colon.     

Colonoscopic polypectomy

The colonoscopic management of 86 patients with polypoid lesions of bleeding from the colon of intermittent nature is discussed. There were 145 polyps found in 85 of these patients. Adenomatous polyps occurring in the sigmoid colon above the reach of the standard sigmoidoscope was the most common finding and pathological diagnosis. Adenocarcinoma of the colon occurred in two patients and invasive carcinoma of a polyp was found in three other patients. Five other patients had polyps that demonstrated a carcinoma in situ. The definitive treatment of these complicated polyps is outlined. The importance of barium enema examination on follow-up of polyp and carcinoma patients and on patients with polyps found at standard sigmoidoscopy is stressed. The possibility of colonoscopic follow-up in lieu of colectomy and ileoproctostomy is suggested for patients with multiple polyps of the colon who do not belong to the familial polyposis group.     

Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia--a case report

BACKGROUND: Adenomatous colonic polyps are accepted as premalignant lesions. There is controversy regarding the significance of the hyperplastic polyp. The aim of this study was to determine the incidence of further polyps in patients with only hyperplastic polyps on a first colonoscopy in comparison with patients without polyps and with adenomatous polyps. METHODS: Ninety patients had only hyperplastic polyps (group I). These patients were paired according to age and sex with subjects having no polyps (group II) and with patients having adenomas (group III). RESULTS: Fifty-six patients in group I had at least one follow-up examination. New polyps were found in 46.4% in group I versus 15.5% in group II (p < 0.001) and 50% in group III (NS). In group I, 30.7% of new polyps were hyperplastic and 69.3% were adenomas. In fact, 32.2% of group I patients developed further adenomas (mean 1.5 +/- 0.8 adenomas). These adenomas occurred 1 to 4 years after the first polypectomy (mean 2.4 +/- 0.8 years). Most of these adenomas were small and tubular, but 16.6% were villous or had severe dysplasia. CONCLUSION: Patients with hyperplastic polyps were 2.4 times more likely to have further adenomas than were those without polyps.     

Unusual tumors of the appendix and pseudomyxoma peritonei

This report covers hyperplastic and neoplastic lesions of the human vermiform appendix that, although unusual, are likely to be encountered by general surgical pathologists. Topics include epithelial neoplasms, hyperplastic polyps, diffuse epithelial hyperplasia, pseudomyxoma peritonei, goblet cell and tubular carcinoid tumors, neuroma, and neurogenous hyperplasia. We discuss recent advances in the prognosis and management of appendiceal carcinoma, current controversies regarding the relationship between ovarian and appendiceal epithelial neoplasms, the concept of the mucinous tumor of uncertain malignant potential (UMP), and practical aspects of reporting pseudomyxoma peritonei. Classical carcinoid tumors are beyond the scope of this article, and primary neoplasms that are so rare they occur in the literature only as isolated case reports are not covered.     

Radiologic features of superficial-type hyperplastic polyps in the large intestine

We studied 38 superficial-type hyperplastic polyps of more than 0.6 cm in size on radiographs to examine their morphologic features. The 38 lesions ranged in size from 0.6 cm to 2.5 cm, and 22 were located in the sigmoid and transverse colon (Table 1, Fig.1). The cross-section and surface configurations of the 38 lesions studied radiographically are illustrated in Fig. 2. 24 lesions without central depression were classified into 5 groups (1-a to 1-e). The 14 other lesions had central depression (2-a). The cross-section configuration was sharp in all lesions, and a finely serrated arrangement was seen in 30 of them. In surface configuration, several granular patterns were seen, but full-blown undulated folds and/or regular granular patterns were characteristic in groups 1-c, 1-d and 2-a. These radiologic features of cross-section and surface configuration may be regarded as a possible means of distinguishing superficial-type hyperplastic polyps from adenomas and carcinomas of the large intestine.     

Clinicopathological studies on pseudosarcomatous lesion of the upper gastrointestinal tract

Thirty-seven cases of pseudosarcomatous lesion (PSL) are studied clinicopathologically on the upper gastrointestinal tract. Majority of the cases showed polypoid tumor lesions, and only minority of them showed non-polypoid lesions. All showed surface erosion or ulcer. Atypical proliferating cells, easily mistaken for sarcoma, were observed in the stroma. The cellular atypia of the stromal cells was related on site and shape; polypoid or non-polypoid. The lesions with severe atypia were observed mainly in the esophago-cardiac junction, lower portion of esophagus and cardia. Non-polypoid lesions showed mild atypia. Immunohistochemically, atypical stromal cells were positive only for vimentin, so considered to be fibroblastic cells. In order to avoid over-diagnosis on biopsy of the upper gastrointestinal tract, recognition of the clinicopathological features of PSL is very important.     

SPECT brain perfusion abnormalities in mild or moderate traumatic brain injury

The accumulation of wild-type p53 protein results in two pathways, cell cycle G1 arrest by p21WAF1/CIP1/SDI1 and apoptosis inhibited by bcl2, which together carry out the tumor suppressor function. Since genetic alterations of p53 are frequently observed in gastric cancers, the expression of p21 and bcl2 may be altered in gastric carcinogenesis. We therefore analyzed normal mucosa, nondysplastic lesions, hyperplastic polyps, adenomas and carcinomas of the human stomach using immuno-histochemistry, polymerase chain reaction-single-strand conformation polymorphism and DNA sequencing. In normal gastric mucosa, the expression of p21, bcl2 and p53 was topographically restricted: a) p21 expression was limited to foveolar epithelial cells; b) bcl2 and p53 expression was confined to only a few regenerative epithelial cells of the mucous neck region. In chronic gastritis or intestinal metaplasia, topographic expression became more obvious. This topographic expression was altered in hyperplastic polyps and adenomas. Hyper-plastic polyp showed an increased p21 and p53 expression with no bcl2 expression. Where as bcl2 expression increased and extended up parabasal and superficial dysplastic epithelium, p21 expression increased and was limited to surface dysplastic epithelium. Weak p53 expression was in full thickness of dysplastic epithelium. p21 and bcl2 expression in adenoma was higher than in intestinal type of carcinoma. In carcinomas, this topography was abrogated, but p53 mutation (36%) was present. There was no relationship between p53, p21 and bcl2 expression. As a result, in normal gastric epithelial cells, there was a precisely ordered topographic pattern of p21, bcl2 and wild-type p53 expression that becomes disordered during neoplasia. These results suggest that altered cell cycle and apoptosis control by wild-type p53 and its mediators appears to be an early event in gastric carcinogenesis that may facilitate tumor progression.     

Aberrant expression of MUC5AC and MUC6 gastric mucin genes in colorectal polyps

Altered mucin glycosylation and the de novo appearance of gastric mucin antigens have been described in colonic adenomas. The purpose of our study was to determine if expression of the gastric mucin genes MUC5AC and MUC6 occurs in colorectal adenomas and whether this correlates with histopathologic criteria of malignant potential. Immunohistochemical staining using antibodies against MUC5AC and MUC6 tandem repeat synthetic peptides was performed on specimens of normal colon mucosa (n = 26), hyperplastic polyps (n = 9) and adenomatous polyps (n = 111). Mucin mRNA levels were determined using RNase protection assays using riboprobes corresponding to unique non-repetitive sequences. MUC5AC and MUC6 staining were rarely detected and of low intensity in normal colon and hyperplastic polyps. The number of immunoreactive polyps and intensity of MUC5AC and MUC6 staining were greatest in larger adenomas of moderate villous histology and dysplasia. MUC5AC and MUC6 staining tended to decrease in highly villous polyps with severe dysplasia. Increased MUC5AC mRNA levels were found in 26/45 of adenomas tested compared with 0/9 normal colon specimens. MUC6 mRNA levels were found in 20/45 of adenomas compared with 1/9 normal colon specimens. MUC5AC and MUC6 mRNA were present more frequently and at higher levels in polyps with intermediate stages of size, villous histology and dysplasia. We conclude that aberrant expression of MUC5AC and MUC6 mucin genes is likely responsible for an expanded repertoire of mucin antigen expression in colorectal neoplasia.     

Decreased risk of subsequent colonic cancer in patients undergoing polypectomy after barium enema: analysis based on data from the preendoscopic era

OBJECTIVE: Published data from the Mayo Clinic gathered during the preendoscopic era were analyzed to show that the risk of subsequent colonic carcinoma is reduced in patients with benign-appearing polyps that are revealed by radiology who then undergo polypectomy. MATERIALS AND METHODS: Data from the Mayo Clinic gathered during a 6-year period before the availability of endoscopy were used to determine the effect on the subsequent risk of colonic carcinoma if the benign-appearing polyps initially revealed by radiology had been removed rather than left in place and followed up by serial barium enemas. Data were from 226 patients with benign-appearing polypoid lesions of the colon that were 1 cm in diameter or larger and had been followed up by periodic barium enemas. The period of radiologic surveillance was 12-229 months (mean, 68 months). Between two and 17 barium enemas (mean, 5.2) were performed on each patient. The clinical follow-up period was 12-242 months (mean, 140 months). RESULTS: Twenty-one adenocarcinomas developed at the site of the index polypoid lesion as found on follow-up barium enema examinations of these patients. Eleven additional adenocarcinomas of the colon were found at sites remote from that of the index lesion. If the index polyp had been removed when initially diagnosed radiologically, 66% fewer subsequent carcinomas would have occurred in these patients during the average of 11 years of clinical follow-up. CONCLUSION: Excision of benign-appearing polyps found on initial barium enema examinations would result in a significant decrease in the subsequent risk of colonic adenocarcinoma.     

Analysis of antigen receptor genes in Hodgkin''s disease

We report three cases of fundic gland polyposis in the stomach identified in three patients who were related. Grossly the numerous polyps covered an area limited to the body and fundus of the stomach, no polyps were found in the antrum, duodenum, colon, or rectum, and histologically, the gastric lesions consisted of numerous hamartomatous polyps, characterized by proliferation of the fundic and cystic glands. The gastric lesions were identified in families without polyposis coli. This type of fundic gland polyposis has never been documented before in the literature.