Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387

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Best Practice & Research Clinical Gastroenterology

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Evaluation and management of gastric epithelial polyps

R. Castro, MD a, *, P. Pimentel-Nunes, MD, PhD a, b, c, M. Dinis-Ribeiro, MD, PhD a, b, c
a
Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
b
CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
c
CIDES-FMUP e Faculty of Medicine of the University of Porto, Porto, Portugal

a b s t r a c t
Keywords: Gastric polyps include a wide spectrum of lesions with different histology and neoplastic potential. They
Gastric epithelial polyp are found in up to 6% of upper gastrointestinal endoscopy and are usually asymptomatic and incidentally
Upper endoscopy
diagnosed, being in the vast majority epithelial gastric polyps. Hyperplastic, fundic gland and adenomas
Hiperplastic polyp
Fundic gland polyp
are the most common types of gastric polyps and, although each type may have typical endoscopic
Gastric adenoma appearances, they all must be sampled at the initial endoscopy for histological assessment. Also, the
Gastric neuroendocrine tumour normal appearing gastric mucosa should be sampled to stage atrophic changes, rule out endoscopically
Inflammatory fibroid polyp non-visible dysplasia and to diagnose Helicobacter pylori. Polyposis syndromes that affect the stomach
Hamartomatous polyp are rare but should be taken into account. Hamartomatous polyps can be found in Juvenile polyposis,
Cowden syndrome and PeutzeJeghers syndrome. On the other hand, multiple fundic gland polyps are
present in the majority of patients with familial adenomatous polyposis. In this study we provide a
comprehensive review on the evaluation and management of gastric epithelial polyps, in this way
helping physicians to properly handle this type of lesions.
© 2017 Elsevier Ltd. All rights reserved.

Introduction
Do to the widespread use of upper endoscopy in the past few
years we have witness an increased detection in gastric polyps that,
as mention above, are usually incidentally found. The current work
is structured in a practical way in order to answer the main issues
imposed by the detection of polyps in upper endoscopy and how to
correctly approach them.
with the same diameter). Intermediate forms are called semi-
pedunculated (Paris 0-Isp) and they should be managed like sessile
polyps [2,3]. Some elevated lesions such as xantomas or sub-
epithelial lesions must not be considered as real polyps and will not
be addressed in this manuscript.
Which type of polyps can usually be found in stomach? Are there
endoscopic features to different them?

What is a gastric polyp?
In practical terms, gastric polyps can be broadly defined as
luminal lesions projecting above the plane of the gastric mucosal
surface [1]. According with Paris classification, a polypoid lesion is
classified as Paris 0-I if its height doubles the thickness of the
adjacent mucosa. Polyps can be further divided into pedunculated
(Paris 0-Ip: with a narrow base) and sessile (Paris 0-Is: base and top
* Corresponding author. Gastroenterology Department, Portuguese Oncology
Institute of Porto, Rua Dr. Anto
nio Bernardino de Almeida, 4200-072 Porto,
Portugal. Fax: þ351 225084001.
E-mail address: rui.arrais.castro@gmail.com (R. Castro).
Hyperplastic polyps represents 30e93% of all gastric epithelial
polyps and are characterized by hyperplastic foveolae with an
inflamed stroma, generally arising in response to a chronic in-
flammatory environment [4,5]. They are the most frequent ones in
countries where Helicobacter pylori infection is common. They can
be sessile or pedunculated, generally with less than 20 mm in
diameter, usually occurring as single polyps in the antrum (Fig. 1a),
although they can arise as multiple lesions anywhere in the gastric
mucosa [1,35e37]. This type of gastric polyp is strongly associated
with chronic gastritis, particularly H. pylori gastritis. Hyperplastic
gastric polyps rarely undergo neoplastic progression (1.5e2.1%) but
are associated with an increased risk of synchronous cancer
occurring elsewhere in the gastric mucosa [6,7]. The risk of

http://dx.doi.org/10.1016/j.bpg.2017.06.001
1521-6918/© 2017 Elsevier Ltd. All rights reserved.
382 R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387
Fig. 1. a. Hyperplastic polyp typical appearance with white light endoscopy. b. The same hyperplastic polyp seen with NBI.
neoplasia in these polyps is increased when they are pedunculated
and bigger than 10 mm [8].
Fundic gland polyps (FGP) represents 16e51% of all gastric
epithelial polyps and are usually multiple, small, transparent and
sessile, often located in gastric fundus and body (Fig. 2a) [4,5].
Fundic gland polyps are more prevalent in Western countries with
lower rates of H. pylori infection and higher rate of PPI therapy,
being the most frequent histological type in this scenario
[5,10,35e37]. They are more frequent in women than in men.
Sporadic fundic gland polyps rarely presents dysplasia (<1%),
however in familial adenomatous polyposis (FAP), multiple polyps
covering the majority of gastric mucosa can be found in 80e93% of
patients and low grade dysplasia may be present in 44e54% of
cases. However, fundic gland polyps, even in patients with FAP,
rarely progress to cancer [9].
Gastric adenomas represents 3e26% of all gastric epithelial
polyps and are strongly associated with atrophic gastritis and in-
testinal metaplasia [4,5]. Solitary, often flat or sessile, generally
with less than 20 mm and frequently found in the antrum (Fig. 3a),
this type of polyps are true neoplasms and precursors of gastric
cancer. Adenomas larger than 20 mm and with villous histology
have a higher risk of neoplastic progression (28e40%) [11,12]. In
fact, some of this polyps harbour malignant cells, even with benign
biopsies. Also, the presence of gastric adenomas is strongly asso-
ciated with synchronous or metachronous gastric adenocarcinoma
[13].
Gastric neuroendocrine tumours (NET) arise in
enterochromaffin-like cells (ECL) and are increasingly identified at
endoscopy, accounting for 0.6e2% of all gastric polyps [14e17].
They are classified in three different types. Type 1 represents 80% of
all gastric neuroendocrine tumours and are typically found in
women (50e70 years) as multiple, small (<10 mm), yellowish
Fig. 2. a. Fundic gland polyp typical appearance with white light endoscopy. b. Fundic gland polyp appearance with NBI.
sessile lesions, with or without central depression or ulceration,
usually located in gastric fundus and body (Fig. 4a), being associ-
ated with autoimmune gastritis (AIG), pernicious anaemia,
achlorhydria and hypergastrinaemia, with the excess of gastrin
being produced by antral G cells [14,18,19]. Type 2 represents 5% of
all gastric neuroendocrine tumours, sharing the same macroscopic
features as type 1 tumours. They occur in patients with Zollinger-
Ellison Syndrome (ZES), usually in the background of multiple
endocrine neoplasia type 1 (MEN1) and are associated with gas-
trinomas that lead to hypergastrinaemia and gastric hyperacidity
[14,20]. Type 3 represents 15% of neuroendocrine gastric tumours
occurring sporadically as solitary, large polyps, ranging from 20 to
50 mm, located anywhere in the stomach without association with
hipergastrinaemia [14,15,21]. This type of gastric NET has the worst
prognosis with the highest rate of metastases.
Hamartomatous polyps are rare in the stomach and include
juvenile polyps, polyps of Peutz-Jeghers and Cowden syndromes
[38]. These lesions can be indistinguishable from hyperplastic
polyps [1]. Solitary juvenile polyps develop in 2% of children and
adolescents, are usually found in the antrum and have no malig-
nant potential. Multiple juvenile gastric polyps, with predominant
location in the body, can be found in 14% of patients with juvenile
polyposis and this condition is associated with gastric malignancy
in 50% of cases [22]. Peutz-Jeghers syndrome is characterized by
familial gastrointestinal hamartomatous polyposis that can be
found scattered all over the stomach in 24% of affected individual
[23]. These polyps have malignant potential, and the average age of
patients presenting with gastric carcinoma is estimated to be 30
years [13]. Gastric harmatomatous can be found in Cowden syn-
drome but gastric malignancy is rarely associated, affecting only 1%
of patients [23].
 R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387 383

Fig. 3. a. Gastric adenoma seen with white light endoscopy. b. Gastric adenoma seen with NBI.

Fig. 4. a. Gastric NET seen with white light endoscopy. b. Gastric NET seen with NBI.

Inflammatory fibroid polyps (IFP), also known as “Vanek tu-

mours”, are rare lesions arising in the submucosa as gastric gran-
ulomas with eosinophilic infiltration and no malignant potential Table 1
[13]. They are most common in meddle-aged women with an Summary of the main features of the different types of gastric polyps.

estimated prevalence of 0.1 % and are usually present as small Histological type Endoscopic features
(<15 mm), sessile, solitary lesions in the gastric pylorus or distal Hiperplastic polyp Location: more common in the antrum
antrum [21,24,39]. Size: generally with less than 20 mm
The main features of the different types of gastric polyps are Number: solitary (66%)/multiple (33%)
summarized in Table 1. Appearance: sessile or pedunculated.
- Small lesions: smooth surface.
- Larger lesions: superficial erosion
What is the role of virtual chromoendoscopy with narrow-band Background mucosa: inflammation, atrophic/
imaging (NBI)? chronic gastritis and intestinal metaplasia with
H. pylori infection are commonly found
Fundic gland polyp Location: fundus and body
Narrow-band imaging (NBI) is an endoscopic imaging technique Size: small (1e5 mm)
that allow enhanced visualization of mucosal microscopic structure Number: usually multiple
and microvascular patterns of the superficial mucosal layer. NBI Appearance: sessile, shiny and translucent
endoscopic appearances, especially the micro vascular patterns, can Background mucosa: typically normal
Adenoma Location: Predominantly in antrum
be useful for predicting the histopathology of gastric polypoid le-
Size: variable
sions [25]. Hyperplasic polyps, which are characterized by dilated Number: solitary (>80%)
and tortuous gastric foveoli within an inflamed and edematous Appearance: sessile or flat with velvety
stroma, generally presents a dense vascular pattern. On the other lobulated surface
hand, fundic gland polyps usually presents a more regular honey Background mucosa: chronic atrophic gastritis
with intestinal metaplasia is common
comb pattern. Irregular patterns such as fine network, core Gastric NET Location: fundus and body
vascular, corkscrew or absent patterns are more often associated (type 1 and 2) Size: usually small (10 mm)
with adenomas/dysplasia and adenocarcinoma [25,26]. In the same Number: multiple
way, NBI can be an important toll when evaluating the surrounding Appearance: yellowish sessile lesions (can
present central ulceration)
mucosa. In a recent multicentre study, the use of NBI increased
Background mucosa: type 1 is usually
sensitivity and specificity for the diagnosis of intestinal metaplasia associated with atrophic gastritis of the body
and dysplasia when compared to white light alone [27]. Regular Inflammatory Location: antrum and pre-pyloric region
ridge/tubulo-villous mucosa and regular vessels, with or without fibroid polyp Size: usually smaller than 30 mm
light blue crest, are found in intestinal metaplasia (Fig. 5). Other- Number: solitary
Appearance: firm, sessile and often ulcerated
wise irregular mucosa with irregular vessels and a complete Background mucosa: can be normal
architectural loss of the mucosal and vascular pattern are strongly
384 R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387
Fig. 5. NBI typical pattern of intestinal metaplasia with regular tubule-villous mucosa
and regular vessels.
Fig. 6. NBI typical appearance of dysplasia with architectural loss of the mucosal and
vascular pattern.
associated with dysplasia [28] (Fig. 6). From our personal experi-
ence, a fundic gland polyp presents a regular circular mucosal
pattern (similar to normal gastric body mucosa) with some regular
and thin vessels (Fig. 2b). A hyperplastic polyp presents a tubular
mucosal pattern, of several shapes, with thick but regular vessels
(Fig. 1b). On the other hand, an adenoma presents a tubular
mucosal pattern with some regular but thin vessels (similar to in-
testinal metaplasia) but generally with a more irregular area of
absent or distorted glands with some irregular vessels, represent-
ing the area of dysplasia (Fig. 3b). Neuroendocrine tumours may
have several shapes but generally they have a central depressed
area with absent/distorted glands with irregular vessels that pre-
sent a centrifugal pattern of growing (Fig. 4b).
Which to biopsy?
As referred above, although some polyps may have typical
endoscopic appearances, they all must be sampled at the initial
endoscopy for histological type assessment and to discard the
presence of dysplasia for which forceps biopsy usually suffices
[11]. Even when there is a high suspicion of neoplastic
polyps, dysplasia should always be confirmed by direct sampling
[29].
How many biopsies?
There is no consensus on the optimal number of biopsy
specimens necessary for the diagnosis. In the past, depending of
the size, at least 6 biopsies were recommended in suspected
malignant lesions but there is now a trend towards fewer bi-
opsies to avoid increase in submucosal fibrosis that may
complicate endoscopic removal [29]. Our suggestion is to take 2
fragments of the most representative area of the polyp, ideally
directed by NBI.
Biopsies of surrounding mucosa? When and Why?
As a general rule, in the presence of a polyp, biopsies should
always be taken at least from the antrum and corpus. In the
presence of hyperplastic polyps and gastric adenomas, the normal
appearing gastric mucosa should be sampled to rule out dysplasia
occurring in the background of metaplastic atrophic gastritis and
to diagnose H. pylori [6,30]. Atrophic gastritis and intestinal
metaplasia are considered gastric precancerous conditions and are
often unevenly distributed throughout the stomach. For adequate
staging and grading, at least four nontargeted biopsies of two
topographic sites (at the lesser and greater curvature, from both
the antrum and the corpus) should be taken and clearly labelled in
separate vials [31]. In gastric neuroendocrine tumours, sampling
of normal appearing gastric mucosa, alongside serum gastric
measurement, can add clues to help distinguish between the
different types [14]. Even with fundic glands polyp a normal
surrounding mucosa will be reassuring when deciding not to
survey these patients.
Which to remove?
Although complete endoscopic removal must be made when-
ever possible, initial assessment of the majority of gastric polyps
can be made by forceps biopsy sampling. However, for polyps
larger than 10 mm forceps biopsy is inadequate to rule out
dysplasia and carcinoma, and these lesions should always be
completely removed [32]. Although sporadic FGP have low to no
malignant potential, there is no consensus about the indications
for endoscopic removal. Some expert suggest that polyps larger
than 10 mm should be removed and others defend that polipec-
tomy is not required for this type of polyps, unless they are
symptomatic [11,30]. Nevertheless, it is our opinion that if larger
than 10 mm then they should be removed. On the other hand, it is
well established that gastric hyperplasic polyps >5 mm and ade-
nomas regardless the size, must be completely removed [30].
However, it is our opinion that probably some hyperplastic polyps
with 5e10 mm may not be removed given the low risk of malig-
nant transformation particularly after H. pylori eradication and
given the fact that this kind of polyp have a tendency to recur. The
majority of type 1 gastric NET are managed by endoscopy and
endoscopic removal is indicated in lesions >10 mm that are
localised to the mucosa or submucosa. All type 2 NET tumours
should be removed, as there is a greater risk of lymph node
involvement and metastases, with endoscopic resection being
indicated for all localised lesions. In type 3 tumours, the role of
endoscopic therapy is limited, being suggested that the decision to
 R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387
Fig. 7. Management of gastric polyps: decision algorithm. 1Hyperplastic polyps are associated with an increased risk of synchronous cancer occurring elsewhere in the gastric
mucosa and surveillance should be offered in cases of severe metaplastic atrophic gastritis. 2Some authors defend that all type II neuroendocrine tumours should be removed
regardless da size. 3Essencial to define the limits of lesion prior or during ESD.
surgically resect these lesions should mirror the principles and
guidelines for gastric adenocarcinomas. Endoscopic submucosal
dissection (ESD) can be an option for lesions smaller than 10 mm
but partial or total gastrectomy with local lymph node resection is
often performed [14]. IFP rarely cause clinical symptoms, however,
large lesions that cause gastric outlet obstruction should be
removed. Nevertheless, given the fact that biopsies are often not
diagnostic in this kind of polyp they are often completely removed
by endoscopic resection [33,39].
How to remove?
Endoscopic resection is recommended for the treatment of
gastric superficial neoplastic lesions that possess a very low risk of
lymph node metastasis. Snaring polipectomy is the preferred
technique for endoscopic resection of Paris 0-Isp or 0-Ip gastric
lesions, hyperplastic and fundic glands polyps. Endoscopic Mucosal
Resection (EMR) is an acceptable option for gastric NET or
dysplastic lesions smaller than 10e15 mm with a very low proba-
bility of advanced histology (type Paris 0-IIa). However, ESD is the
treatment of choice for most gastric superficial neoplastic lesions,
allowing higher en bloc resection rates for larger lesions with lower
levels of recurrence [29].
Which needs surveillance? How?
After initial endoscopy with histologic assessment of gastric
polyps and sampling of normal appearing gastric mucosa, it is
important to define which patients need surveillance and how it
should be done. Surveillance by upper endoscopy is not routinely
recommended for sporadic FGP without dysplasia once progres-
sion to gastric cancer is rare. Whoever, in young patients with
numerous polyps and where biopsies demonstrate dysplasia, FAP
should be considered and excluded with colonoscopy. If this
diagnosis is confirmed, upper endoscopy at every two years
should be performed [11,34]. As previously referred, in the pres-
ence of hyperplastic polyps, additional histological assessment of
385
any visible lesion and normal appearing mucosa must be made.
After excluding dysplasia in the polyp and surrounding mucosa,
surveillance is recommended with a single upper endoscopy at 1
year. Additionally H. pylori should be tested and treated if present.
If no residual polyp is found after one year, further surveillance is
not recommended (unless the patient presents extensive atrophy
or metaplasia, then upper endoscopy should be repeated at 3
years intervals) [11,31] All gastric adenomas must be removed
regardless the size. In case of complete resection of dysplastic
lesions or well differentiated intramucosal adenocarcinoma up to
20 mm, surveillance could be made with endoscopy after 3e6
months and then annually. After piecemeal resection or presence
of positive lateral margins without meeting criteria for surgery, an
endoscopy with biopsies is recommended after 3 and 9 months
and then annually [29]. Once again, additional histologic sampling
of any visible lesion and normal appearing mucosa must be made
due to strong association with atrophic gastritis, intestinal
metaplasia and synchronous or metachronous adenocarcinoma
[5,13]. The majority of type 1 NET are managed by endoscopy. As
mentioned above, lesions >10 mm should be resected either by
EMR or ESD, being that lesions <10 mm can be managed through
annually endoscopy surveillance [14]. IFP are believed to have no
malignant potential and no endoscopic follow-up is recom-
mended after initial histologic confirmation [13]. Finally, it is also
important to remember that chronic atrophic gastritis, intestinal
metaplasia and dysplasia are independent risk factors for gastric
adenocarcinoma and also requires surveillance. Independently of
the polyp histology, when atrophic gastritis or intestinal meta-
plasia are present both in antrum and corpus, upper endoscopy
with biopsies should be repeated at every three years. Patients
with low grade dysplasia in the absence of defined lesion should
receive follow-up within 1 year after diagnosis. For patients with
high grade dysplasia in the absence of defined lesions, immediate
endoscopic reassessment, ideally with chromoendoscopy, with
extensive biopsy sampling and surveillance at 6 month to 1 year
intervals is indicated [31].
386 R. Castro et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 381e387
Pratice points
 Gastric polyps include a wide spectrum of lesions with
different histology and neoplastic potential. Although
endoscopic typical appearance, all gastric polyps must be
sample for histologic assessment at least at the initial
endoscopy.
 In the presence of gastric polyp, biopsies of normal
appearing mucosa should always be taken at least from
the antrum and corpus.
 Sporadic FGP and IFP have a negligible risk of presenting
dysplasia and, after initial endoscopic and histologic as-
sessments, no further surveillance is needed. FAP must
be considered when a high number of FGP, frequently
presenting dysplasia, are found in young patients.
 Hyperplastic gastric polyps are strongly associated with
H. pylori infection. They rarely undergo neoplastic pro-
gression but are associated with an increased risk of
synchronous cancer occurring elsewhere in the gastric
mucosa. Therefore, H. pylori must be treated if present
and surveillance should be offered in cases of severe
metaplastic atrophic gastritis.
 Adenomas are true neoplasms and precursors of gastric
cancer and usually occur in a background of atrophic
gastritis and intestinal metaplasia. All gastric adenomas
must be removed and surveillance is mandatory since
they are strongly associated with synchronous or meta-
chronous adenocarcinoma.
 Type 1 is the most common type of gastric NET and
usually occur in association with autoimmune gastritis.
Small lesions (<10 mm) can be handle with annual
endoscopic surveillance and larger lesions generally can
be endoscopically removed.
 Hamartomatous polyps are often associated with polyp-
osis syndromes. According to the syndrome, they can
present different risk of neoplastic progression and, his-
tologically, they can be indistinguishable of hyperplastic
polyps.
Research agenda
 Clarify the role of virtual chromoendoscopy in the evalu-
ation of gastric polyps with adequate classification of
different patterns according to histological type.
 Clarify the importance and ideal number of target bi-
opsies assisted by virtual chromoendoscopy in the diag-
nosis of dysplastic polyps.
 Clarify the surveillance schedule after removal of each
type of gastric polyps.
Summary
The correct evaluation and management of gastric polyps can
be a challenge even for the best endoscopists. In the limited time
of an upper endoscopy, several decisions have to be made ac-
cording to the different findings. As summary, and respecting the
practical nature of this review, we propose a decision algorithm
that allows an acceptable approach through the most typical
scenarios (Fig. 7).
Conflict of interest
None.
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