Successful Treatment of a Rare Presentation of a Common Disease: Intense Proton Pump Inhibitor Therapy Regressed a Gastric Mass Due to Peptic Ulcer Disease

Abstract

The worldwide annual incidence and prevalence of Peptic Ulcer Disease (PUD) has been reported to be 0.10-0.19% for both and causes dyspepsia in 10% of patients. The majority of PUD is caused by H. Pylori and NSAID use. It can be complicated by bleeding, perforation, penetration, and obstruction. Due to proton pump inhibitor (PPI) use and H. Pylori eradication, the prevalence of lesions seen in the gastroduodenal area has started to change. Gastric polyps have been reported in 4.8% of patients who had endoscopy. An 85-year-old female with a past medical history significant for hypertension, hyperlipidemia and diabetes who initially was admitted for headache, nausea and vomiting. Work-up with a CT head and MRI brain were negative. CT abdomen and pelvis showed a diffusely thickened stomach at the gastric body. Endoscopy showed a 4 by 7 cm antral and pre-pyloric mass that was excavated. The pylorus appeared deformed and was difficult to traverse with the endoscope. Upper GI series with small bowel follow through also revealed the mass in the gastric antrum along the greater curvature. Subsequently, she underwent an EUS that showed a large polypoid ulcerated mass extending from the greater curvature of the gastric body to the proximal duodenal bulb. The mass had irregular borders with invasion into the muscularis propria. It had 1.7 cm intramural thickness with endosonographic staging of T3N0Mx. Biopsies showed gastric mucosa with reactive and hyperplastic changes, negative for H. Pylori. She refused further intervention and opted for conservative management with Pantoprazole 40 mg two times a day. Repeat endoscopy in 3 months only showed a clean based 6 by 10 mm gastric ulcer in the stomach. Biopsies from ulcer edge showed hyperplastic foveolar epithelium with mild chronic inflammation. This patient presented with a gastric hyperplastic inflammatory mass in the setting of PUD. Hyperplastic polyps are seen in less than 20% of gastric polyps and classically are associated with H. Pylori, however, there has been increase in proportion of such polyps without concomitant H. Pylori infection. The prevalence of carcinoma is less than 2% among hyperplastic polyps which is more frequent in those larger than 2 cm. Common practice is to excise hyperplastic polyps larger than 1 cm. Studies have shown regression of small hyperplastic polyps after H. Pylori eradication. This case demonstrates a success story of treating a large gastric hyperplastic polyp with PPI.Figure 1Figure 2Figure 3