Gastric Outlet Obstruction Caused by Prolapsed Gastric Polyp Into the Pyloric Channel

Abstract

A54-year-old morbidly obese African American woman with a significant past medical history of sarcoidosis, hypertension, and congestive heart failure presented to the emergency room with a 1-week history of abdominal pain, nausea, and vomiting. The patient had moderate tenderness to palpation of the right upper and left upper quadrants on physical examination, with no rebound or guarding. A computerized tomography scan of the abdomen was obtained in the emergency room that showed gastric outlet obstruction and possible intussusception (Figure A). An upper endoscopy showed multiple pedunculated gastric polyps varying in size from 5 to 40 mm. One pedunculated polyp appeared to have prolapsed into the duodenal bulb, causing complete gastric outlet obstruction (Figure B). Multiple maneuvers were not successful in pulling the polyp back into the stomach, including grasping the stalk with a foreignbody forceps, snare, epinephrine injection to shrink the polyp, suction using a banding cap, and the use of glucagon intravenously. A repeat esophagogastroduodenoscopy (EGD) was performed the next day with plans to attempt different maneuvers under fluoroscopy, however, on repeat endoscopy, the polyp appeared to have spontaneously flipped back into the stomach (Figure C) and subsequently was removed with a hot snare. The patient noted a significant improvement in abdominal pain after polyp removal, and was able to tolerate diet well. The pathology of the removed polyp was consistent with a tubular adenoma with intramucosal focal invasive adenocarcinoma. Surgery was considered high risk in view of the patient’s multiple risk factors. Because of the presence of multiple gastric polyps, the patient underwent sequential EGDs with polypectomy. All polyps showed invasive adenocarcinoma that had reached the stalk margin. The patient was deemed high risk for surgery because of her morbid obesity, frequent asthma attacks, and because of possible distant spread. Computerized tomography of the abdomen, pelvis, and chest showed liver lesions and mediastinal lymph nodes. An endoscopic ultrasound–guided fine-needle aspiration of the liver and the mediastinal lymph nodes was performed, however, it showed a granuloma, which was consistent with sarcoidosis but could not exclude metastatic disease. The patient currently is receiving chemotherapy. Gastric polyps are found in approximately 6% of all upper-endoscopy procedures in the United States. In the vast majority of cases, gastric polyps are asymptomatic. However, in some cases, gastric polyps can present with gastrointestinal bleeding, and, less commonly, with gastric outlet obstruction. Pyloric obstruction has been described in case reports as a manifestation of pedunculated polyps in the gastric antrum intermittently prolapsing into or through the pylorus. In our patient, based on her symptoms, images, and the endoscopic findings, it appears that the polyp had prolapsed and