Eradication of Gastric Polyposis after Withdrawal of PPI Therapy

Abstract

Purpose: Long term proton pump inhibitor (PPI) use is associated with up to four fold increase risk of Fundic Gland Polyps (FGP); the risk of malignant transformation is negligible. These polyps develop because of parietal cell hyperplasia resulting from acid suppression and consist of microcysts composed of chief and parietal cells. Clinically FGP are usually silent. We report a case of massive gastric polyposis associated with iron deficiency anemia that resolved with cessation of PPI therapy. A 54 years old female with reflux symptoms and esophagitis, documented by endoscopy, was treated with PPI (lansoprazole 30 mg twice daily) for over 10 years. She presented two years ago with iron deficiency anemia. Outside endoscopy showed diffuse proximal gastric polyposis. Biopsies demonstrated FGP. Colonoscopy was negative except for 8 mm mixed hyperplastic adenomatous polyp. Because of increasing size of the gastric polyps and anemia she was referred for further management. On referral, Hemoglobin and Hematocrit were 11.0 and 32, respectively, associated with iron deficiency anemia (ferritin level of 6) treated with intravenous iron therapy. Family history was negative for Familial Adenomatous Polyps. Her father died of lung cancer; her mother has had bilateral mastectomy for breast cancer. Her mother's siblings had a history of colon, breast, prostate and lung cancer. She has 2 children alive and well. Repeat upper Endoscopy showed massive polyposis of the proximal stomach; too numerous to count (see Figure 1). There was no duodenal, specifically, peri-ampullary lesions. Several of the larger polyps were removed. Histology showed fundic gland polyps with dilated foveolae. No Helicobacter pylori organisms were seen. It was recommended for the patient to discontinue PPI therapy. Reflux symptoms were treated with sucralfate. Follow up endoscopy 24 months later showed resolution of gastric polyposis; Iron deficiency anemia has resolved Hemoglobin and Hematocrit were 14 and 42. She has not required any iron therapy since. To our knowledge, this is the first documented case of eradication of massive gastric polyposis associated with iron deficiency anemia that resolved with cessation of PPI therapy. FGP attributable to PPI therapy can presents with iron deficiency anemia.Figure 1: No Caption available.