2008 Fundic Gland Polyps: Not Always an Innocent Bystander

Abstract

INTRODUCTION: Fundic gland polyps (FGP) are often found incidentally on endoscopy in 1.9% of patients, with most being asymptomatic. However, as in this case, FGP have been a source of upper gastrointestinal bleeding (UGB) leading to hospitalization. CASE DESCRIPTION/METHODS: An 81-year-old male with GERD and non-dysplastic Barrett’s Esophagus, presented to the emergency department with coffee ground emesis for 2 weeks. He denied NSAID, steroid, or alcohol use. GERD is well controlled on Omeprazole 40 mg daily which he has taken for the past 10 years. He denies dysphagia, abdominal pain or weight loss. No family history of gastric or colon cancer or familial polyposis syndromes. Patient with normal heart rate and blood pressure however with orthostatic hypotension. Physical exam without abdominal tenderness and rectal vault without stool on exam. Hemoglobin 11.1 on presentation with last hemoglobin 13.3 four months ago. Last EGD 2 years ago revealed non-dysplastic Barrett’s Esophagus, along with a few sub centimeter non-bleeding FGP, confirmed with biopsy. A colonoscopy 4 years prior had one tubular adenoma. Patient underwent EGD and was found to have multiple gastric body polyps; several of the largest polyps had active oozing blood. The bleeding polyps measured 12 mm in size and were removed via hot snare polypectomy. Normal remainder of exam. Afterward he remained clinically stable with no further bleeding and was discharged with Omeprazole daily. Histology revealed FGP with low grade dysplasia. H.pylori was negative on biopsies. Repeat EGD 8 weeks later removed the remaining polyps and gastric mapping was performed. Histology revealed FGP without dysplasia and no gastric intestinal metaplasia was noted. Patient has done well since with no further bleeding. DISCUSSION: Bleeding gastric FGP are rarely considered in the differential of UGB, however in this case, led to the patient’s hospitalization. Long-term (>5 years) proton-pump inhibitors (PPI) have been associated with fourfold increased risk of FGP, with regression often seen upon withdrawal of PPI. This patient brings a unique case in which guidelines recommend long-term daily PPI for his Barrett’s Esophagus, however has already had complications from his growing FGP on Omeprazole. FGP can also be associated with polyposis syndromes. Malignancy is rare in sporadic and PPI induced FDG but can be seen in up to 4.2% of patients with familial adenomatous polyposis. The removal of FGP can potentially limit the risk of future bleeding as seen in this case.