| Keywords
Hamartoma, stomach, EUS, polyps, and polypectomy
Introduction
A 50 year-old woman was evaluated for abdominal
pain and vomiting.
Methods for EUS Capture
Endoscopic ultrasound (EUS) was performed
with the Olympus UM-20 radial sector scan using both water
filled lumen and balloon techniques at scanning frequencies
of 7.5 and 12 mHz frequencies.
Case/Body
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Figure
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Figure
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Figure
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A 50-yr. Korean female presented to Fitzsimons
Army Medical Center with a complaint of recurrent mid epigastric
abdominal pain after meals. The pain began 2 years previously
and was initially sporadic in onset. Over the proceeding 6
months the patient noted increased frequency of these painful
episodes. The pattern of symptoms was clearly postprandial
fullness, followed by progressive distention of the upper
mid abdomen accompanied by nausea and the urge to vomit. Complete
relief of distention and pain symptoms, after vomiting food
or bilious material was typical. Consumption of solid meals
appeared to precede episodes of pain and vomiting more often
that with liquids. Over the preceding 3-6 months the patient
sustained a documented 10-lbs. weight loss. Past medical and
surgical history was remarkable for a bleeding duodenal ulcer
surgically treated by vagotomy, antrectomy and ulcer oversew
at the age of 28 yr. in the Republic of South Korea. The patient
was a homemaker and otherwise healthy. Physical examination
was remarkable for a thin female, standing 4 feet 10 inches
tall and a weight of 95 lbs. There was a well healed surgical
scar in the epigastrium, but no palpable fullness, mass or
tenderness. Laboratory tests showed complete blood count and
multi-phasic chemistries to be normal. Upper endoscopy was
performed under conscious sedation. The gastric remnant was
bile stained with a Billroth I outlet anatomy. The opening
of the gastroenteric anastamosis measured approximately 2.5
cm in widest dimension. Along the gastric side of the anastamosis
was a 3.0 cm bi-lobed, broad based polypoid mass, figure 1.
The mass was mobile and freely prolapsed to-and-fro from the
stomach into the small bowel during endoscopic examination.
The polypoid mass was soft and deformable as it prolapsed
through the gastroenteric anastamosis, but nearly completely
occluded the anastamotic orifice. Biopsies of the mass were
consistent with hamartoma. Endoscopic ultrasound (EUS) was
performed with the Olympus UM-20 radial sector scan using
both water filled lumen and balloon techniques at scanning
frequencies of 7.5 and 12 mHz frequencies. EUS of the mass
revealed the polyp to arise from the first two sonographic
layers with a central, tubular anechoic, fluid density in
the center of the polyp extending to the base, figure 2. Doppler
flow of the polyp stalk was not available. No extragastric
masses or adenopathy were identified by EUS. The patient was
offered endoscopic and surgical methods to remove this polypoid
mass, she preferred endoscopic technique. Esophagogastroduodenoscopy
(EGD) was again performed under conscious sedation. The base
of the polypoid mass was injected with 1:10,000 epinephrine
causing blanching vasoconstriction and a pseudo-stalk, which
was snared and amputated with a monopolar electrocautery snare.
The field was dry and the polyp removed using a Roth retrieval
net. Post procedure the patient was given sulcrafate 1 gm
ac and hs and omperazole 20 mg qd for 1 month. The gross section
of the polyp is shown in figure 3. The polyp was typical of
a hamartoma with numerous glandular cystic elements and stranding
of smooth muscle fibers in the base. Large > 3 mm vessels
are seen in the stalk of this polyp. The patient has remained
asymptomatic for over 1 year since endoscopic removal of the
polyp.
Discussion/Summary
Statement
Hamartomatous polyps of the stomach may
occur as part of a polyposis syndrome or as in this case report,
sporadic. The cause of gastric hamartomatous polyp formation
is unknown. Some have theorized that the deranged differentiation
of oxyntic glands is the basic mechanism in the pathogenesis
of these polyps(1). The sporadic form of hamartomatous polyps
are more common in adult women then adult men, usually located
in the fundus or gastric body, and appear to decrease in number
with advancing age(2). Congo red staining has shown that these
polyps are associated with extensive acid formation(2). Helicobacter
pylori infection is actually much lower among patients with
hamartomatous polyps, than in healthy controls and persons
with hyperplastic gastric polyp(3). Most gastric hamartomatous
polyps are asymptomatic and co-incidentally discovered during
the investigation of dyspeptic complaints. However, hamartomatous
polyps may become large and cause intussusception and obstruction.
This is a typical feature of the multiple hamartomatous polyps
seen with Peutz-Jeggher Syndrome, (4,5) but reported only
twice previously among non-polyposis patients. Murphy, et
al, reported a case of a 15 month old with short period of
vomiting and radiographic evidence of gastric outlet obstruction,
surgically found to have a large pedunculated hamartomatous
polyp arising from the gastric fundus and obstructing the
proximal jejunum(6). Itoh, et al, reported on a 41 year old
female with 3 cm pedunculated hamartomatous polyp from the
gastric fundus causing epigastric discomfort(7) Like our patient,
this patient's symptoms we cured by endoscopic polypectomy.
The EUS features of hamartomatous polyps consist of thickening
of the first and second sonographic layers. When oxyntic glands
are large and higher scanning frequencies are used, cystic
spaces may be seen in the first sonographic layer( 8,9)
In our patient, the EUS findings were helpful since it suggested
a large vascular structure in the polyp base. Our endoscopic
polypectomy technique was modified to include submucosal injection
of 1:10,000 epinephrine into the polyp base before monopolar
electrocautery snare amputation. Recent reports of neoplastic
transformation of hamartomatous polyps further support the
use of EUS to examine for features of malignancy, i.e., adenopathy
or infiltration(10,11). In our patient, EUS findings reassured
the patient and treatment team that endoluminal removal of
the polyp would be adequate.
In conclusion, we report an unusual case
of a large hamartomatous polyp causing symptoms of gastric
outlet obstruction that was staged by EUS and managed by endoluminal
resection.
References
1. Sipponen P, Laxen F, Seppala K. Cystic
hamartomatous gastric polyps: a disorder of oxyntic glands
Histopatology. 1983;7:729-37
2. Iishi H, Tatsuta M, Okuda S Clincopath features and
natural history of gastric hamartomous polyps Dig Dis
Sci. 1989;34:890-4
3. Sakai M, Tatsuta M, Hirasawa R, Iishi H, Baba M, Yokota
Y, Ikeda F. Low prevalence of Helicobacter pylori infection
in patients with hamartomatous fundic polyps. Dig
Dis Sci. 1998;43:766-72.
4. Sudduth RH, Bute BG, Schoelkopf L, Smith MT, Freeman SR,
McNally PR Small bowel obstruction in a patient with Peutz-Jeghers
Syndrome: The role of intra-operative endoscopy Gastrointestinal
Endosc. 1992;32:69-72.
5. DeLuca N, Chia Y, Gorard DA Total gastrointestinal
endoscopy in the management of Peutz-Jegher's syndrome
Postgrad Med J. 1998;74:745-7
6. Murphy S, Shaw K, Blanchard H Report of three gastric
tumors in children. J Pediatr Surg. 1994;29:1202-4.
7. Itoh K, Tsuchigami T, Matsukawa T, Takahashi M, Honma K,
Ishimara Y. Unusual gastric polyp showing submucosal proliferation
of glands: case report and literature review J
Gastroenterol. 1998;33:720-3.
8. Kubo S, Akahoshi K, Wakiyama S, Fujimaru T, Kojima H, Nakanishi
K, Harada N, Nawata H Endosographic features of solitary
gastric hamartomatous polyp. Endoscopy. 2000;32:S39
9. Hizawa K, Matsumoto T, Kouzuki T, Suekane H, Esaki M, Fujishima
M. Cystic submucosal tumors in the gastrointestinal tract:
endosonographic findings and endoscopic removal Endoscopy.
2000;32:712-4.
10. Bajanda L, Berguiristain A, Villar JM, Cosme A, Castiella
A, Arriola JA, Arenas JI Gastric adenocarcinoma in hamartomatous
polyp in Peutz-Jeghers syndrome Gastroenterol
Hepatol. 1996;19;452-5.
11. Defago MR, Higa AL, Campra JL, Paradelo M, Uehara A, Torres
Mazzucchi MH, Videla R Carcinoma in situ arising in a
gastric hamartomatous polyp in a patient with Peutz-Jeghers
syndrome Endoscopy. 1996;28:267.
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