Inflammatory Fibroid Polyp of the Gastroesophageal Junction in a Patient Presenting with Melena

Abstract

Purpose: Inflammatory fibroid polyps (IFPs) are uncommon masses that have been reported throughout the gastrointestinal (GI) tract. They are difficult to distinguish endoscopically and echo-endoscopically from other gastrointestinal mesenchymal tumors. To the best of our knowledge, no cases of IFPs at the location of the GE junction presenting with upper GI bleed were previously reported in the medical literature. Methods: We present a case of an inflammatory fibroid polyp of the gastroesophageal (GE) junction, initially thought to be a gastrointestinal stromal tumor (GIST), in a patient presenting with melena. Results: A 66-year-old female presented with a two-week history of weakness and fatigue associated with melena. Esophagogastroduodenoscopy (EGD) revealed a 3 cm mass with central ulceration at the GE junction, which was likely the source of her upper GI bleed. Biopsies were negative for malignancy, but the mass appeared suspicious. The patient was referred for endoscopic ultrasound (EUS), which revealed a hypoechoic mass that appeared to arise from the muscularis propria. Both the endoscopic and echo-endoscopic appearance of the mass were suspicious for a GIST. EUS-guided fine-needle aspiration was nondiagnostic. The patient was referred for surgery and oncology was consulted for possible adjuvant chemotherapy. The patient underwent gastric wedge resection with removal of the cardia and tissues were sent for pathology, which surprisingly came back with a diagnosis of inflammatory fibroid polyp. Gross upper GI bleeding is a rare presenting symptom of IFPs, which are mostly encountered as incidental polyps during EGD. The endoscopic appearance of an IFP and GIST are very similar. EUS is usually helpful, as GISTs nearly always arise from the muscularis propria, while IFPs are typically submucosal lesions. This case was unique in that the IFP involved the muscularis propria, making it very difficult to differentiate from a GIST on EUS. Immunohistochemistry is the only reliable method of properly distinguishing between a GIST and an IFP. GISTs are typically positive for DOG-1 and CD-117, while IFPs are negative for those markers. Conclusion: Due to the difficulty in distinguishing between inflammatory fibroid polyps and other mesenchymal tumors (including GISTs) by endoscopic appearance and even on EUS, the use of immunohistochemistry is essential to help differentiate between them, as their treatment and prognosis can differ markedly.