S3031 Successful Endoscopic Resection of Portal Hypertensive Gastric Polyps

Abstract

INTRODUCTION: Portal hypertension is a common complication of decompensated cirrhosis. Portal hypertensive polyposis (PHP) is a rare complication of portal hypertension with a prevalence of 0.9–1.3%. The precise etiology is unknown but portal pressure-related congestion may induce proliferation and angiogenesis in PHP. Thrombocytopenia (platelet count < 130×109/L) and Model For End-Stage Liver Disease (MELD) score >16 are independent risk factors for the development of PHP (1). Gastric polyposis related to PHP does not appear to have malignant potential and there are currently no guidelines for their management. CASE DESCRIPTION/METHODS: A 61-year-old female with decompensated cirrhosis (MELD score of 21) secondary to non-alcoholic fatty liver disease with esophageal varices and hepatic encephalopathy presented with chronic normocytic anemia. Iron studies were consistent with a combination of iron deficiency and anemia of chronic disease. The patient denied hematemesis, melena and hematochezia. Her hemoglobin was 7g/dL, INR of 1.4, and platelet count of 121 × 109/L. Upper endoscopy showed severe portal hypertensive gastropathy in the fundus, cardia and gastric body. In the antrum, there were hyperplastic appearing polyps with a maximum diameter of 5 cm (Figure 1). Portions of the polyp were ulcerated and prolapsing into the duodenal bulb. Small hyperplastic appearing polyps were also noted in the first part of the duodenum. Biopsies of the antral polyps revealed hyperplastic polyps with surface ulceration and granulation tissue. Random antral and gastric body biopsies revealed surface hyperplastic changes. After pathology results returned, repeat upper endoscopy was performed for therapeutic intervention. The 3 cm antral polyp was successfully removed using a detachable snare (Figure 2), while the 5 cm polyp was debulked piecemeal using a 10mm hot snare (Figure 3). The patient was also monitored overnight without signs or symptoms of any immediate complications or gastrointestinal bleeding. DISCUSSION: PHP, while rare, can be a cause of anemia in patients with cirrhosis and portal hypertension. Although the management of these lesions is not guideline-based at this time, this case highlights that endoscopic resection can be achieved with commonly available endoscopic tools. Patients should be counseled on risk of post-polypectomy hemorrhage.Figure 1.: Evidence of portal hypertensive gastropathy and view of gastric polyps from the proximal antrum.Figure 2.: 3cm antral polyp successfully removed using a detachable snare.Figure 3.: 5cm gastric polyp covering the pylorus debulked piecemeal using 10mm hot snare.