So, the second talk that I have is on gastric polyps and cancer, and I don't have any disclosures to make for this. We'll be talking about various types of gastric polyps, including their malignant potential, how should we be identifying them endoscopically, and how can we manage them better. Before we delve into the actual talk, I want to highlight the fact that any gastric lesion or polyps could be of two different types. This includes epithelial lesions or polyps, which could be sessile or pedunculated. But here, the mucosal surface will have some form of visible abnormality. And other type of polyp where the mucosal surface or the epithelium may appear completely normal because these are sub-epithelial category of polyps. Today, we'll be focusing on epithelial gastric polyps. These are fundigland type, hypoplastic, adenoma, hematomatous, or it could be rarely neuroendocrine tumor type as well. And these are generally diagnosed based on biopsy. On the other hand, these sub-epithelial polyps generally require endoscopic ultrasound exam to examine what they are and what layer they are originating from. These are generally leomyoma, just lipoma or genus. Epithelial gastric polyps are found incidentally in general, and very rarely they are cause of bleeding, anemia, and obstruction if they're located in the pyloric channel or antrum and large enough. Overall, lower malignant potential, roughly 2% of polyps larger than one centimeter could harbor risk of malignancy, and that is why careful evaluation is recommended, especially if they are larger. Gland type of polyps are the most common one. They are located generally in corpus of the stomach. They are multiple in numbers and small. They have a smooth pale surface, lighter than the background mucosa, and on optical enhancement, they have small round pits with honeycomb pattern. On sampling, they would show cystically dilated glands lined by gastric type of mucosa. Now, these polyps are, in general, sporadic, occur without any particular pathology or cause, but we have been seeing more and more of this since patients are using PPI, and many of them are using it for a long time, and this could be related to changes in gastrin levels. However, there is another entity that you should be mindful about. Whenever you see multiple fundigland polyps in stomach, especially in young individuals, and finding of low-grade dysplasia or coexistent adenoma in small bowel, you should be thinking of familial adenomatous polyposis. In general, this type of polyps have low malignant potential unless they are large or they have underlying familial adenomatous polyposis syndrome. They should be resected when they are large enough, more than a centimeter, to understand if there is any concern for underlying malignancy. For sporadic fundigland polyps, that is still low. However, they should be removed when there is any concern for atypical features on the surface or irregular surface, and especially if they are located in antrum. Whenever you have an individual with FAP, you should be examining most of these polyps to look for any atypical features, and all the polyps with atypical features should be removed. Now, in cases where there is a role of chronic PPI use, you should reevaluate whether they really need the PPI in the long run, and if possible, completely stop them and put them on alternating agents if possible, or at least decrease the dose. If they are sporadic, then there is no need for surveillance. Moving on to hyperplastic type of polyps, and these are generally single, located in antrum. Many times, they are associated in the setting of some sort of chronic injury, like an ulcer or gastrectomy-related, you know, chronic injury, and they are adjacent to these areas. Now, multiple hyperplastic polyps could be seen in certain settings, including miniaturized disease due to changes in the hormonal milieu. These are generally appearing as if there is a, you know, inflammatory polyp, because they appear with ulceration, erosion, or white exudates on the surface with red-brownish appearance, but this is a misnomer. An inflammatory fibroid polyp, on the other hand, is a true inflammatory polyp, but this is submucosal in nature, so be mindful that these are not inflammatory, but they do appear as if there is inflammation going on. Under optical enhancement, you may identify Willis pits, contrary to the colonic adenomas, but these are hyperplastic polyps of stomach and a dense vascular pattern. On biopsy, they will have proliferation of surface povular cells lining elongated and distorted pits that extend deep inside the lamina propria. Now, these are associated with H. pylori-associated changes in stomach, including GIM and atrophy, in almost one-fourth of cases, and they do regress with H. pylori eradication. So whenever you see this type of polyps in stomach, you should be examining the surrounding mucosa for changes of CAG and GIM that we discussed. You should be performing a separate biopsy in the stomach for looking for GIM, H. pylori, and CAG. Most of the hyperplastic polyps are benign. However, there is a slightly higher risk than fundigland polyps of conversion to cancer, and especially when they're larger than one centimeter, they have a risk of progression to cancer. Dysplasia, on the other hand, could be found in almost 10 to 19% of cases in large hyperplastic polyps. So you should be removing any polyps larger than a centimeter in hyperplastic. Now, there is a higher risk of synchronous cancer in stomach because these individuals also have H. pylori and related changes. Most of this data is from the Eastern world, so we don't have registries or prospective data available from Northern America to guide us, but these are helpful numbers to estimate and discuss with your patient. Regarding the management for this type of polyps, so they require histologic confirmation, although you suspect them endoscopically, you have to perform some sort of sampling to prove that they are hyperplastic. And depending on underlying changes of H. pylori, GIM, etc., you need to plan if they need eradication for H. pylori before repeating the endoscopy for resection, because many of them just regress with H. pylori eradication. Repeat the endoscopy in six months after eradication. And if they are larger than one centimeter, pedunculated, causing symptoms, then they should be removed. And they should be removed also if they are already three centimeters in size because there is a high risk of malignancy. Surveillance in these individuals should be based on presence of underlying gastric intestinal metaplasia and associated changes. Moving on to adenoma polyps in the stomach. And as we can imagine, these are not that common. These are single small lesions located in antrum or in incisor, difficult to identify. They may appear as pink lobulated lesions. Compared to colonoscopy world here, the adenomas, their features are not that well-defined to guide us. They may have a slit-like crypts and regular white opaque substance, but these are not very specific. Prevalence in the Western world has been reported at a very wide variable range from 0.5 to 10%. And synchronous gastric cancer is present in almost a third of these patients. Now 50% of adenomas in stomach larger than two centimeters may already have a focus of gastric cancer. So any adenoma of any size should be resected whenever it's safe to do so and should be done N-block if preferred. Detailed evaluation for underlying changes in the same polyp as well as surrounding mucosa as well as any synchronous lesions in stomach is very important. The British Society of Gastroenterology Guidelines, there is a ASG guideline in process, but it hasn't been out yet. But ASG guidelines recommend N-block resection for polyps less than 15 millimeter and adenoma with endoscopic mucosal resection or dissection, but using ESD preferably whenever they are larger than 15 millimeter due to possibility of high risk of invasion. And these individuals require follow-up at 6 to 12 months for synchronous lesions. Now different type of polyps and not encountered so frequently are hematoma type of polyps or hematomatous polyps, and they could be associated with any underlying syndrome or they may happen just in isolation as solitary lesion. These include juvenile polyps, Pugh's-Jager type of polyps, and Cowden syndrome. So juvenile polyps are solitary, rare, and they are generally benign if they are only one or two. They are located in antrum. They have irregular crypts lined by normal gastric epithelium with possible stromal hemorrhage, ulceration on surface, and some inflammatory component. However, if you have multiple juvenile type of polyps, you should be thinking of screening for juvenile polyposis syndrome because these are the individuals who will benefit from annual screening because of very high risk of gastric malignancy. We discussed briefly about FAP, but a point that I want to highlight here is that almost 30 to 100 percent of individuals with FAP have some sort of gastric polyps. Three of them are fundigland type of polyps, but there is a 5 percent subset of individuals who have adenoma in this category, and with FAP, you could have low-grade dysplasia in a fundigland polyp as well as separate lesions in stomach. So every time you have a patient with FAP, you need to do a careful evaluation to rule out underlying pathology. These individuals would require surveillance on an annual basis. Finally, gastric polyps in the setting of cirrhosis, mainly from portal hypertension-related changes. I have encountered this actually frequently being in transplant center in multiple patients with portal hypertension as well as in individuals with portal hypertension from underlying cardiac etiology. These individuals are, you know, undergoing endoscopy for evaluation of anemia. They have multiple hyperplastic polyps, and this is not well described in literature, but could be related to changes in liver clearance of gastrine and some contribution from underlying TBI use. And this could be symptomatic as we discussed that this type of polyps could contribute to anemia by some chronic blood loss and may require resection for management of anemia. So in general, gastric polyps require adequate insufflation during the endoscopy, including clearing of all bubbles and debris to identify them. Whenever you encounter gastric polyps, look for other polyps in stomach, document how many there are, document the location and size of the largest polyp. Photographic documentation of, if not all, representative polyps is important. Funding line polyps could be diagnosed endoscopically and biopsy can be ignored if you are confident in your endoscopic diagnosis, but most of the other polyps require histologic confirmation. So be well-versed with that. Whenever you encounter multiple polyps, it would be good to obtain representative samples of different types in different bottles so that a strategy can be planned afterwards. Complete polypectomy, as we discussed, is recommended by ASU guidelines for any funding line polyp larger than 10 millimeter and hypoplastic polyps of, you know, 5 to 10 millimeters and adenoma of any size. Studies have shown that we take biopsies from this polyps, which, you know, gives you the diagnosis, but then there is no endoscopic resection performed. And we need to improve our strategy to remove all of the polyps larger than 10 millimeter using a SNAP. Although there is no North American guideline focusing on gastric polyps, I have included this algorithm, which I kind of covered in our talk today from British Society of Gastroenterology on management of gastric polyps, which you can print and put it in your endoscopy, you know, room to refer to for management. So in summary, gastric polyps are common and there are various types, so know them well. You know, high quality endoscopy is must, including clearing of all debris and bubbles from stomach. Whenever you encounter a young individual with multiple fundigland polyps, think of FAP, screen them, not only biopsy the polyp, but also biopsy and examine the background mucosa, eradicate H. pylori, because this is helpful in terms of hypoplastic and adenoma type of polyps, and examine the stomach at the same time for synchronous lesions and biopsy them, you know, for proper management. Thank you so much again for this wonderful invitation, and it has been a delight to be here.

gastric polyps

endoscopic identification

malignant potential

management

histologic confirmation