Endoscopic Treatment of Intermittent Gastric Outlet Obstruction Caused by a Prolapsing Gastric Antral Polyp

Abstract

Purpose: Gastric outlet obstruction often presents with nausea and vomiting and usually develops over weeks to months. The most common causes of gastric outlet obstruction are peptic ulcers, malignancy, bezoars, foreign bodies, and pyloric stenosis. Methods: We report a case of intermittent gastric obstruction caused by a prolapsing hyperplastic gastric antral polyp. Results: A healthy 44-year-old female presented with 3 months of intermittent dull mid abdominal pain, nausea and intermittent non-bloody, non-bilious vomiting. She also described early satiety and a weight loss of 8 pounds over the 3 months. She was otherwise healthy and took no medications. On physical exam she had normal bowel sounds, and mild tenderness over the epigastric region. She had a negative Murphy's sign, and the spleen and liver were normal. Her complete blood count was normal, with no anemia. Upper endoscopy was recommended to further investigate the patient's pain, nausea, vomiting and weight loss. On upper endoscopy, a 3 cm pedunculated, prolapsing, polyp was found arising in the gastric antrum and causing ball-valve effect within the pylorus and near complete obstruction of the pyloric channel. The polyp was observed to cause intermittent gastric outlet obstruction. The polyp was completely resected by a monopolar polypectomy using a large snare and sent for pathology. Pathology showed a hyperplastic polyp without evidence of metaplasia, dysplasia or malignancy. Random gastric biopsies showed chronic inactive gastritis and no evidence of Helicobacter pylori. At the follow-up 12 months after the polypectomy, the patient remained symptom free. Conclusion: We report the case of a patient with intermittent symptomatic gastric outlet obstruction caused by a benign prolapsing gastric polyp treated by endoscopic snare resection. There are 39 previously reported cases of gastric polyps leading to gastric outlet obstruction. Gastric polyps causing gastric outlet obstruction are more common in females (23 cases) with median age of onset of 72 years in females. Previously reported polyps arise from the antrum and have a median size of 5 cm (1.5-8 cm). They can be managed surgically with excision, or endoscopically with snare polypectomy or endoscopic mucosal resection (EMR) of sessile polyps. The median size of endoscopically removed polyps is 3 cm, with largest reported in the literature being 8 cm. Complications of endoscopic management include bleeding and perforation. Gastric polyps should be considered in the differential diagnosis of a patient who present with intermittent gastric outlet obstruction. Endoscopic management with snare resection is a good option if technically feasible and can result in a long term response.