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Keywords
EUS, fibrovascular polyp, duodenal obstruction.
Disclaimer
No experimental devices or medications were used in this report.
Introduction
A woman presented with the new onset of vomiting, and endoscopy revealed a mass at the outlet of the duodenal bulb. Endoscopic evaluation and management are reported.
Methods for Image Capture/Processing
SVHS tape with video capture was used.
Case/Body
A 75-year-old woman reported a two week history of recurrent vomiting. The vomiting occured postprandially and was unpredictable. She did not have abdominal pain, but by the time of evaluation could not eat solids, and was on a liquid only diet. She has not had this problem in the past, and has no history of gastroparesis or previous ulcer disease.
An upper GI endoscopy on this woman showed a mass at the duodenal bulb outlet. When originally seen, the mass was smooth, and non-ulcerated. It appeared to be sessile, on a broad base. The initial biopsy revealed foveolar metaplasia, and the patient was referred for further evaluation.
Her past history included the removal of an ovarian teratoma 30 years previously and coronary artery disease.
The patient was a chronic tobacco user.
Her medications included 81 mg of aspirin daily and an antihypertensive.
Her physical exam was unremarkable for her age.
An EUS was performed (Video Clip 1) which revealed a circumscribed, slightly hyperechoic mass in echo-layer 3 (submucosa). No large vessels were seen using color-Dopplar, and no significant vessels were seen under the lesion. Based on the EUS findings, the differential diagnosis included items such as carcinoid tumor, lipoma, and lymphoma. Since some of these diagnoses required definitive surgery, it was felt that biopsies into the previous biopsy site should be performed to assess the deeper aspects of the lesion. An EGD was performed with multiple biopsies into the core of the lesion (Video Clip 2). As suggested by the video, the mass seemed moderately firm, but not rock-hard.
Biopsies returned inflammation and a non-descript inflammatory cell process, that was not obviously a carcinoid tumor or a malignancy. Based on these findings, the patient was brought back for an attempt at endoscopic removal.
At the time of the anticipated endoscopic removal, 4 ml of 1:10,000 epinephrine was injected into the base of the lesion and 20 ml of saline was infiltrated submucosally. The lesion did not lift well. Since EUS suggested that the lesion was in the submucosa, a snare was placed around the lesion (Video Clip 3), and the lesion was manipulated to try and ensure separation from the deep duodenal wall. Using a mixed cut and coagulation at 20 Watt settings, the cut was difficult . After removal of the mass, dense fibrous tissue appeared to remain behind (Video Clip 4). Since the fibrous core seemed different than the polyp body, attempts were made to biopsy this material for histologic review in a separate container, in case a dysplastic process remained. However, samples could not be removed with forceps. A rat-toothed grasper was therefore used to remove samples (Video Clip 5), and the procedure terminated.
Histology revealed Brunner's gland hyperplasia (Figure 1), with polypoid features suggesting hamartoma (Figure 2). The dense material removed with the rat-toothed grasper revealed fibrosis consistent with a fibroid polyp (Figure 3). The fibrous core was left in-situ.
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Figure 1 |
Figure 2 |
Figure 3 |
The patient has returned to solid food without vomiting following the endoscopy. She has been maintained on a proton-pump inhibitor medication. A follow-up endoscopy after 3 months showed healing at the polypectomy site without evidence of recurrent or residual growth of the index lesion.
Discussion
Inflammatory fibroid polyps rare lesions which are difficult to distinguish by inspection from other gastrointestinal tumors. The have been reported throughout the gastrointestinal tract, but most commonly occur in the stomach (1-5). Hamartoma is suggested when there is a disorganized growth of mature cellular elements native to the organ, in which the growth is found.
Inflammatory fibroid polyps generally present with bleeding (6) but to our knowledge, obstruction at the duodenal bulb outlet has not been reported.
Fibrovascular polyps are usually found during esophagogastroscopy (7), and after being found, are often evaluated by EUS (8) to assess the depth of the lesion, the vascularity, and the possibility for endoscopic removal. If possible, endoscopic management is the therapy of choice (9).
Although rare, the clinician should be aware of this entity, since endoscopic management can be performed even with relatively large lesions, and open surgery can be avoided. The natural history appears to be benign (10) and malignant degeneration has not been reported, so even incomplete resections can be followed expectantly.
References
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2. Nishiyama Y, Koyama S, Andoh A, Kishi Y, Yoshikawa K, Ishizuka I, Yokono T, Fujiyama Y. Gastric inflammatory fibroid polyp treated with Helicobacter pylori eradication therapy. Intern Med. 2003 Mar;42(3):263-7.
3. Savargaonkar P, Morgenstern N, Bhuiya T. Inflammatory fibroid polyp of the ileum causing intussusception: report of two cases with emphasis on cytologic diagnosis. Diagn Cytopathol. 2003 Apr;28(4):217-21.
4. Nakase H, Mimura J, Kawasaki T, Itani T, Komori H, Hashimoto K, Okazaki K, Chiba T. Endoscopic resection of small inflammatory fibroid polyp of the colon. Intern Med. 2000 Jan;39(1):25-7.
5. Costa PM, Marques A, Tavora, Oliveira E, Diaz M. Inflammatory fibroid polyp of the esophagus. Dis Esophagus. 2000;13(1):75-9.
6. Soon MS, Lin OS. Inflammatory fibroid polyp of the duodenum. Surg Endosc. 2000 Jan;14(1):86.
7. Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Endoscopic features of gastric inflammatory fibroid polyps.
Am J Gastroenterol. 1996 Aug;91(8):1595-8.
8. Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Gastric inflammatory fibroid polyps: endoscopic ultrasonographic analysis in comparison with the histology. Gastrointest Endosc. 1997 Jul;46(1):53-7.
9. Tada S, Iida M, Yao T, Matsui T, Kuwano Y, Hasuda S, Fujishima M. Endoscopic removal of inflammatory fibroid polyps of the stomach. Am J Gastroenterol. 1991 Sep;86(9):1247-50.
10. Daum O, Hes O, Vanecek T, Benes Z, Sima R, Zamecnik M, Mukensnabl P, Hadravska S, Curik R, Michal M. Vanek's tumor (inflammatory fibroid polyp). Report of 18 cases and comparison with three cases of original Vanek's series. Ann Diagn Pathol. 2003 Dec;7(6):337-47.
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