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Gastritis cystica polyposa (GCP) is a rare condition, characterised by the formation of a large polypoid structure seen in the stomach, most frequently after a partial gastrectomy. It is most frequently seen in the operated stomach on the gastric side of any anastamosis.In the postoperative stomach, the suggested pathogenesis revolves around chronic inflammation due to either reflux of small bowel content or a reaction to sutures.1,2 The polyp frequently appears endoscopically and radiographically similar to gastric malignancy. Histologically is characterised by polypoid hyperplasia of gastric mucosa with cystically dilated glandular structures.1We present to our knowledge the first reported case of GCP in Australasia in a patient with an intact stomach.Case reportThis 62-year-old lady with shortness of breath and epigastric pain was referred from her general practitioner. Investigations revealed an iron deficiency anaemia, Hb 106 MCV 69 and positive faecal occult blood screen. She underwent colonoscopy, which was normal, and gastroscopy which revealed a small hiatus hernia, a short segment of Barretts oesophagus and a large polypoid mass in the antrum of the stomach with superficial ulceration, and multiple satellite lesions (Figure 1). Helicobacter pylori urease test was negative.Initial histology returned as benign ulcerated lesion but in the context of the clinical scenario further tissue was required to exclude a malignancy. This lady was referred for surgical follow-up and staging CT, on the presumption of gastric malignancy. The CT demonstrated the polypoid lesion on the greater curvature of the stomach with no associated lymphadenopathy (Figure 2).After numerous biopsies the lesion was removed with a snare polypectomy. Histology was confirmed as gastritis cystica polyposa profunda (Figure 3) with incomplete excision and a further polypectomy required for complete clearance. After 12 months of quarterly then two 6-monthly endoscopies, our patient continues on omeprazole 40 mg OD and annual endoscopy as potential for recurrence is unknown. Figure 1. Endoscopic appearance of gastritis cystical polyposa greater curvature of the stomach (main image) with satellite lesions (inset image) Figure 2. CT image demonstrating polyp attached to greater curvature of the stomach (arrows), reversed prone image Figure 3. Histological appearance of lesion, demonstrating cystic regions confined to the mucosa and sub-mucosa (arrow) with distorted mucinous glands (white arrow) Discussion In the case reported we have demonstrated the difficulty in accurately diagnosing a lesion with appearances endoscopically and radiographically of an early gastric cancer but which is histologically benign. The natural history of this lesion is unclear and a number of gastroscopies were needed to be confident of accurate diagnosis. GCP remains a rare diagnosis and aside from a few reported cases in intact stomachs,3-6seems confined to those with any form of gastro-enterostomy.2,7 This leads to the suggestion that it is secondary to chronic mucosal irritation from reflux of small bowel content.1,2,7Because GCP has been identified alongside early gastric cancer, it has been suggested to be a pre-cancerous lesion, but remains difficult to prove.4,8 Histologically GCP is confined to the sub-mucosa, and as such is amenable to endoscopic resection.4-6 Identifying histological features are of polypoid mucosal hyperplasia with cystic dilatation of the gastric glands and localised infiltration with inflammatory cells.1,7 In this case the initial diagnosis was uncertain and numerous attempts at biopsy were performed before a snare polypectomy was performed to complete excision. With a certain diagnosis of GCP follow up endoscopies have not found evidence of recurrence. There is limited experience of management of GCP lesions and further reporting is necessary to characterise the disease progression. In centres where endoscopic ultrasound and endoscopic sub-mucosal resection are more routinely available this is an attractive lesion to resect and successful resection has been performed up to 20 mm in size.4 From a management perspective it would not be surprising to hear of surgical resection being performed for such lesions as endoscopically and radiographically it has features of gastric malignancy.2,8 In this instance it was detected after investigation for symptomatic iron deficiency anaemia which is associated with gastrointestinal lesions, both benign and malignant. Further reports are necessary to determine the disease progression to clarify its potential as a pre-malignant lesion as well as to identify causative factors in the un-operated stomach.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Ian Bloomfield, Surgical Registrar, Tauranga Hospital, Tauranga; Jeremy Rossaak, Department of Surgery, University of Auckland and Department of Surgery, Tauranga Hospital, Tauranga

Acknowledgements

Correspondence

Correspondence: Jeremy Rossaak, Department of Surgery, Tauranga Hospital, PO Box 12024, Tauranga, New Zealand.

Correspondence Email

Jeremy.Rossaak@bopdhb.govt.nz

Competing Interests

- Franzin G, Novelli P. Gastritis Cystica Profunda. Histopathology. 1981 Sep;5(5):535-47.-- Ozenc AM, Ruacan S, Aran O. Gastritis Cystica Polyposa. Arch Surg. 1988 Mar;123(3)372-3.-- Hirasaki S, Tanmizu M Tsubouchi E, et al. Gastritis Cystica Polyposa concomitant with gastric inflammatory fibroid polyp occurring in an unoperated stomach. Intern Med. 2005 Jan;44(1):46-9.-- Park CH, Park JM, Jung CK, et al. Early gastric cancer associated with Gastritis Cystica Polyposa in the unoperated stomach treated by endoscopic submucosal dissection. Gastrointest Endosc. 2009;69(6):47-50.-- Tuncer K, Alkanat M, Musoglu A, Aydin A. Gastritis Cystica Polyposa found in an unoperated stomach: An unusual case treated by endoscopic polypectomy. Endoscopy. 2003;35:882.-- Park JS, Myung SJ Jung HY, et al. Endoscopic treatment of gastritis cystica polyposa found in an un-operated stomach. Gastrointest Endosc. 2001 Jul;54(1):101-3.-- Littler ER, Gleibermann E. Gastritis Cystica Polyposa. (Gastric mucosal prolapse at gastroenterostomy site, with cystic and infiltrative epithelial hyperplasia). Cancer. 1972 Jan;29(1):205-9.-- Aoyagi K, Koufuji K, Yano S, et al. Two cases of cancer in the remnant stomach derived from Gastritis Cystica Polyposa. The Kurume Medical Journal .2000;47(3):243-8.-- Wu MT, Pan HB, Lai PH et al. CT of Gastritis Cystica Polyposa. Abdom Imaging. 1994;19:8-10.-

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Gastritis cystica polyposa (GCP) is a rare condition, characterised by the formation of a large polypoid structure seen in the stomach, most frequently after a partial gastrectomy. It is most frequently seen in the operated stomach on the gastric side of any anastamosis.In the postoperative stomach, the suggested pathogenesis revolves around chronic inflammation due to either reflux of small bowel content or a reaction to sutures.1,2 The polyp frequently appears endoscopically and radiographically similar to gastric malignancy. Histologically is characterised by polypoid hyperplasia of gastric mucosa with cystically dilated glandular structures.1We present to our knowledge the first reported case of GCP in Australasia in a patient with an intact stomach.Case reportThis 62-year-old lady with shortness of breath and epigastric pain was referred from her general practitioner. Investigations revealed an iron deficiency anaemia, Hb 106 MCV 69 and positive faecal occult blood screen. She underwent colonoscopy, which was normal, and gastroscopy which revealed a small hiatus hernia, a short segment of Barretts oesophagus and a large polypoid mass in the antrum of the stomach with superficial ulceration, and multiple satellite lesions (Figure 1). Helicobacter pylori urease test was negative.Initial histology returned as benign ulcerated lesion but in the context of the clinical scenario further tissue was required to exclude a malignancy. This lady was referred for surgical follow-up and staging CT, on the presumption of gastric malignancy. The CT demonstrated the polypoid lesion on the greater curvature of the stomach with no associated lymphadenopathy (Figure 2).After numerous biopsies the lesion was removed with a snare polypectomy. Histology was confirmed as gastritis cystica polyposa profunda (Figure 3) with incomplete excision and a further polypectomy required for complete clearance. After 12 months of quarterly then two 6-monthly endoscopies, our patient continues on omeprazole 40 mg OD and annual endoscopy as potential for recurrence is unknown. Figure 1. Endoscopic appearance of gastritis cystical polyposa greater curvature of the stomach (main image) with satellite lesions (inset image) Figure 2. CT image demonstrating polyp attached to greater curvature of the stomach (arrows), reversed prone image Figure 3. Histological appearance of lesion, demonstrating cystic regions confined to the mucosa and sub-mucosa (arrow) with distorted mucinous glands (white arrow) Discussion In the case reported we have demonstrated the difficulty in accurately diagnosing a lesion with appearances endoscopically and radiographically of an early gastric cancer but which is histologically benign. The natural history of this lesion is unclear and a number of gastroscopies were needed to be confident of accurate diagnosis. GCP remains a rare diagnosis and aside from a few reported cases in intact stomachs,3-6seems confined to those with any form of gastro-enterostomy.2,7 This leads to the suggestion that it is secondary to chronic mucosal irritation from reflux of small bowel content.1,2,7Because GCP has been identified alongside early gastric cancer, it has been suggested to be a pre-cancerous lesion, but remains difficult to prove.4,8 Histologically GCP is confined to the sub-mucosa, and as such is amenable to endoscopic resection.4-6 Identifying histological features are of polypoid mucosal hyperplasia with cystic dilatation of the gastric glands and localised infiltration with inflammatory cells.1,7 In this case the initial diagnosis was uncertain and numerous attempts at biopsy were performed before a snare polypectomy was performed to complete excision. With a certain diagnosis of GCP follow up endoscopies have not found evidence of recurrence. There is limited experience of management of GCP lesions and further reporting is necessary to characterise the disease progression. In centres where endoscopic ultrasound and endoscopic sub-mucosal resection are more routinely available this is an attractive lesion to resect and successful resection has been performed up to 20 mm in size.4 From a management perspective it would not be surprising to hear of surgical resection being performed for such lesions as endoscopically and radiographically it has features of gastric malignancy.2,8 In this instance it was detected after investigation for symptomatic iron deficiency anaemia which is associated with gastrointestinal lesions, both benign and malignant. Further reports are necessary to determine the disease progression to clarify its potential as a pre-malignant lesion as well as to identify causative factors in the un-operated stomach.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Ian Bloomfield, Surgical Registrar, Tauranga Hospital, Tauranga; Jeremy Rossaak, Department of Surgery, University of Auckland and Department of Surgery, Tauranga Hospital, Tauranga

Acknowledgements

Correspondence

Correspondence: Jeremy Rossaak, Department of Surgery, Tauranga Hospital, PO Box 12024, Tauranga, New Zealand.

Correspondence Email

Jeremy.Rossaak@bopdhb.govt.nz

Competing Interests

- Franzin G, Novelli P. Gastritis Cystica Profunda. Histopathology. 1981 Sep;5(5):535-47.-- Ozenc AM, Ruacan S, Aran O. Gastritis Cystica Polyposa. Arch Surg. 1988 Mar;123(3)372-3.-- Hirasaki S, Tanmizu M Tsubouchi E, et al. Gastritis Cystica Polyposa concomitant with gastric inflammatory fibroid polyp occurring in an unoperated stomach. Intern Med. 2005 Jan;44(1):46-9.-- Park CH, Park JM, Jung CK, et al. Early gastric cancer associated with Gastritis Cystica Polyposa in the unoperated stomach treated by endoscopic submucosal dissection. Gastrointest Endosc. 2009;69(6):47-50.-- Tuncer K, Alkanat M, Musoglu A, Aydin A. Gastritis Cystica Polyposa found in an unoperated stomach: An unusual case treated by endoscopic polypectomy. Endoscopy. 2003;35:882.-- Park JS, Myung SJ Jung HY, et al. Endoscopic treatment of gastritis cystica polyposa found in an un-operated stomach. Gastrointest Endosc. 2001 Jul;54(1):101-3.-- Littler ER, Gleibermann E. Gastritis Cystica Polyposa. (Gastric mucosal prolapse at gastroenterostomy site, with cystic and infiltrative epithelial hyperplasia). Cancer. 1972 Jan;29(1):205-9.-- Aoyagi K, Koufuji K, Yano S, et al. Two cases of cancer in the remnant stomach derived from Gastritis Cystica Polyposa. The Kurume Medical Journal .2000;47(3):243-8.-- Wu MT, Pan HB, Lai PH et al. CT of Gastritis Cystica Polyposa. Abdom Imaging. 1994;19:8-10.-

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Gastritis cystica polyposa (GCP) is a rare condition, characterised by the formation of a large polypoid structure seen in the stomach, most frequently after a partial gastrectomy. It is most frequently seen in the operated stomach on the gastric side of any anastamosis.In the postoperative stomach, the suggested pathogenesis revolves around chronic inflammation due to either reflux of small bowel content or a reaction to sutures.1,2 The polyp frequently appears endoscopically and radiographically similar to gastric malignancy. Histologically is characterised by polypoid hyperplasia of gastric mucosa with cystically dilated glandular structures.1We present to our knowledge the first reported case of GCP in Australasia in a patient with an intact stomach.Case reportThis 62-year-old lady with shortness of breath and epigastric pain was referred from her general practitioner. Investigations revealed an iron deficiency anaemia, Hb 106 MCV 69 and positive faecal occult blood screen. She underwent colonoscopy, which was normal, and gastroscopy which revealed a small hiatus hernia, a short segment of Barretts oesophagus and a large polypoid mass in the antrum of the stomach with superficial ulceration, and multiple satellite lesions (Figure 1). Helicobacter pylori urease test was negative.Initial histology returned as benign ulcerated lesion but in the context of the clinical scenario further tissue was required to exclude a malignancy. This lady was referred for surgical follow-up and staging CT, on the presumption of gastric malignancy. The CT demonstrated the polypoid lesion on the greater curvature of the stomach with no associated lymphadenopathy (Figure 2).After numerous biopsies the lesion was removed with a snare polypectomy. Histology was confirmed as gastritis cystica polyposa profunda (Figure 3) with incomplete excision and a further polypectomy required for complete clearance. After 12 months of quarterly then two 6-monthly endoscopies, our patient continues on omeprazole 40 mg OD and annual endoscopy as potential for recurrence is unknown. Figure 1. Endoscopic appearance of gastritis cystical polyposa greater curvature of the stomach (main image) with satellite lesions (inset image) Figure 2. CT image demonstrating polyp attached to greater curvature of the stomach (arrows), reversed prone image Figure 3. Histological appearance of lesion, demonstrating cystic regions confined to the mucosa and sub-mucosa (arrow) with distorted mucinous glands (white arrow) Discussion In the case reported we have demonstrated the difficulty in accurately diagnosing a lesion with appearances endoscopically and radiographically of an early gastric cancer but which is histologically benign. The natural history of this lesion is unclear and a number of gastroscopies were needed to be confident of accurate diagnosis. GCP remains a rare diagnosis and aside from a few reported cases in intact stomachs,3-6seems confined to those with any form of gastro-enterostomy.2,7 This leads to the suggestion that it is secondary to chronic mucosal irritation from reflux of small bowel content.1,2,7Because GCP has been identified alongside early gastric cancer, it has been suggested to be a pre-cancerous lesion, but remains difficult to prove.4,8 Histologically GCP is confined to the sub-mucosa, and as such is amenable to endoscopic resection.4-6 Identifying histological features are of polypoid mucosal hyperplasia with cystic dilatation of the gastric glands and localised infiltration with inflammatory cells.1,7 In this case the initial diagnosis was uncertain and numerous attempts at biopsy were performed before a snare polypectomy was performed to complete excision. With a certain diagnosis of GCP follow up endoscopies have not found evidence of recurrence. There is limited experience of management of GCP lesions and further reporting is necessary to characterise the disease progression. In centres where endoscopic ultrasound and endoscopic sub-mucosal resection are more routinely available this is an attractive lesion to resect and successful resection has been performed up to 20 mm in size.4 From a management perspective it would not be surprising to hear of surgical resection being performed for such lesions as endoscopically and radiographically it has features of gastric malignancy.2,8 In this instance it was detected after investigation for symptomatic iron deficiency anaemia which is associated with gastrointestinal lesions, both benign and malignant. Further reports are necessary to determine the disease progression to clarify its potential as a pre-malignant lesion as well as to identify causative factors in the un-operated stomach.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Ian Bloomfield, Surgical Registrar, Tauranga Hospital, Tauranga; Jeremy Rossaak, Department of Surgery, University of Auckland and Department of Surgery, Tauranga Hospital, Tauranga

Acknowledgements

Correspondence

Correspondence: Jeremy Rossaak, Department of Surgery, Tauranga Hospital, PO Box 12024, Tauranga, New Zealand.

Correspondence Email

Jeremy.Rossaak@bopdhb.govt.nz

Competing Interests

- Franzin G, Novelli P. Gastritis Cystica Profunda. Histopathology. 1981 Sep;5(5):535-47.-- Ozenc AM, Ruacan S, Aran O. Gastritis Cystica Polyposa. Arch Surg. 1988 Mar;123(3)372-3.-- Hirasaki S, Tanmizu M Tsubouchi E, et al. Gastritis Cystica Polyposa concomitant with gastric inflammatory fibroid polyp occurring in an unoperated stomach. Intern Med. 2005 Jan;44(1):46-9.-- Park CH, Park JM, Jung CK, et al. Early gastric cancer associated with Gastritis Cystica Polyposa in the unoperated stomach treated by endoscopic submucosal dissection. Gastrointest Endosc. 2009;69(6):47-50.-- Tuncer K, Alkanat M, Musoglu A, Aydin A. Gastritis Cystica Polyposa found in an unoperated stomach: An unusual case treated by endoscopic polypectomy. Endoscopy. 2003;35:882.-- Park JS, Myung SJ Jung HY, et al. Endoscopic treatment of gastritis cystica polyposa found in an un-operated stomach. Gastrointest Endosc. 2001 Jul;54(1):101-3.-- Littler ER, Gleibermann E. Gastritis Cystica Polyposa. (Gastric mucosal prolapse at gastroenterostomy site, with cystic and infiltrative epithelial hyperplasia). Cancer. 1972 Jan;29(1):205-9.-- Aoyagi K, Koufuji K, Yano S, et al. Two cases of cancer in the remnant stomach derived from Gastritis Cystica Polyposa. The Kurume Medical Journal .2000;47(3):243-8.-- Wu MT, Pan HB, Lai PH et al. CT of Gastritis Cystica Polyposa. Abdom Imaging. 1994;19:8-10.-

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