Fundic gland polyps: not so trivial entity and worth evaluation

Abstract

We read with great interest the recent article by Burt.1Burt W.R Gastric fundic gland polyps.Gastroenterology. 2003; 125: 1462-1469Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar The article elegantly highlights many different aspects of gastric fundic gland polyps (FGPs), which are not infrequently encountered at endoscopy particularly with the widespread use of long-term proton pump inhibitor therapy in dyspeptic patients. The conclusion of the trivial nature of non-syndromic FGPs echoes that of Elster et al.2Elster K Eidt H Ottenjann R Rosch W Seifert E Drusenkorperzysten, eine polypoide Lasion der Magenschleimhaut.Dtsch Med Wochenschr. 1977; 6: 183-187Crossref Scopus (46) Google Scholar in 1977 when they also suggested that FGPs were entirely harmless. We beg to disagree with this conclusion for the following reasons. In his paper, Dr. Burt quite rightly discusses at length the importance of FGPs in the setting of familial adenomatous polyposis coli (FAP) and attenuated polyposis coli syndromes, both in terms of their neoplastic potential and also the possible coexistence of colonic and small bowel neoplasms. There are also isolated reports of high-grade dysplasia occurring in sporadic FGPs.3Jalving M Koornstra J.J Gotz J.M van der Waaij L.A de Jong S Zwart N et al.High-grade dysplasia in fundic gland polyps a case report and review of the literature.Eur J Gastroenterol Hepatol. 2003; 15: 1229-1233Crossref PubMed Scopus (71) Google Scholar In a large case series of FGPs, Wu et al.4Wu T.T Kornacki S Rashid A Dysplasia and dysregulation of proliferation of foveolar and surface epithelia of fundic gland polyps from patients with familial adenomatous polyposis.Am J Surg Pathol. 1998; 23: 293-298Crossref Scopus (135) Google Scholar found that the incidence of dysplasia in syndromic and sporadic FGPs was 25% and 1%, respectively. Thus, the development of dysplasia in sporadic FGPs should be considered an unusual but not an unknown phenomenon. Secondly, Burt does not deal with the important observation that colonic polyps and carcinomas can coexist in a small but significant proportion of patients with FGPS, even in the absence of FAP or attenuated polyposis coli syndromes. In a matched control study of 64 patients with sporadic FGPs and 64 patients without FGPs, Jung et al.5Jung A Vieth M Meir O Stolte M Fundic gland polyps (Elsters cysts) of the gastric mucosa.A marker for colorectal epithelial neoplasia? Pathol Res Pract. 2002; 198: 731-734Crossref PubMed Scopus (34) Google Scholar found that, in the group with sporadic FGPs colorectal adenomas were found in 28.1%, high-grade dysplasia in 4.7% and adenocarcinoma in 12.5% patients respectively whereas in the control group only 9.3% developed colonic adenomas. In our own recent study, we have found colonic polyps in 19 of 32 patients (59.3%) with sporadic FGPs.6Maguire A Sebastian S Crotty P O’Connor H Buckley M O’Morain C Gastric polyps frequency, types, endoscopic features and associations.Endoscopy. 2003; (in press).Google Scholar It is conceivable that hypergastrinemia associated with PPI-induced acid suppression may act as a growth-promoting tumoral agent for colonic epithelial cells. In addition there are data to suggest that PPI therapy may be involved in inducing beta-catenin mutation, which has a role in colon carcinogenesis.7Abraham S.C Park S.J Mugartehui L Hamilton S.R Wu T.T Sporadic fundic gland polyps with epithelial dysplasia evidence for preferential targeting for mutations in the adenomatous polyposis coli gene.Am J Pathol. 2002; 161: 1735-1742Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Hence evaluation of the colon in patients with FGPs is a reasonable recommendation. In summary, we feel that a long-term follow-up study of patients with FGPs and its association with colonic polyps is warranted. Until such a study is reported, it is probably premature to dismiss the finding of FGPs at endoscopy as “trivial.”