Hamartomatous gastric polyp A case report of atypical presentation 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 2 weeks ultrasound shows a picture of acute pancreatitis due to obstructive jaundice In upper endoscopy initially we find a large pedunculated gastric polyp passing through pyloric ring up to 2nd part of duodenum causing a compression on duodenal papilla It was withdrawn back to stomach after grasping with a snare Then removed by piecemeal technique after injection of the pedicle with diluted adrenaline Bleeding after snaring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 with complete resolution of all symptoms 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 while the symdromatic hamartomatous polyps has a higher malignancy risk which increases with age range 1 to 33 between 30 and 60 years 4 Gastric polyps may intussusept 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 which was radiated to the back for 2 weeks This condition was followed by yellowish discolouration of sclera associated with dark color urine and low grade fever which has 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 9µmol L and direct bilirubin was 7 µmol L Other investigations revealed Amylase 1300 U L Lipase 650 U L Abdominal ultrasound revealed bulky pancreas dilated Pancreatic Duct dilated Common bile duct and Intra hepatic biliary radicle dilatation All of the forementioned data indicated that the patient was suffering from obstructive jaundice complicated by acute pancreatitis Patient was referred for endoscopic evaluation In upper endoscopy initially we saw pyloric canal partially obstructed by a smooth surfaced pili like structure When passed to bulb of duodenum we observed a large pedunculated polyp 12x8 cm in size This polyp was originated from stomach passing down to the 2nd part of duodenum It was withdrawn back to stomach after grasping with snare Figure
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 hemoclips for control of bleeding In our case we used a combined method of bleeding control adrenaline hemoclip for high risk of bleeding 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
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