I will start with a case and then I will open up to questions and answers and have a discussion among our panel. So and again, you can type your questions in the Q&A and we'll get to them, either type them or discuss them in our panel discussion. So this case is a 78 year old with a history of multiple gastric polyps, ranging from one to two centimeters in size, and they were hyperplastic on histology, H. pylori status was negative. And the last repeat endoscopy showed on biopsy, there was low grade dysplasia in a polyp and the patient was referred for further management. This series of slides are showing the four larger polyps. So there were two larger polyps on the greater curve, two on the lesser curve. The ones of the greater curve were two centimeters or greater. And then there were some smaller polyps. Anything that any comments or anything that you would prioritize? No, I think this is, you know, very well for photo documentation is pretty good. So congrats on that. And then you also label that where they are exactly located, which is helpful in terms of, you know, future intervention and subsequent workup. I would also emphasize that this hyperplastic polyps are very difficult sometimes to examine because of component of ulceration and bleeding. And whenever suspecting that they are larger than one centimeter, endoscopic resection would be a good strategy to examine them further. So these four were being one centimeter or greater were selected for polypectomy. And the first one, which was the largest, showed hyperplastic polyp with low grade dysplasia. The second one, which was two centimeters, showed hyperplastic polyp without evidence of dysplasia. Now, the third one showed intramucosal carcinoma with arising out of high grade dysplasia in this hyperplastic polyp. And then the last one was a hyperplastic polyp without dysplasia. I know you mentioned this in your slide, but I feel like it's worth reiterating. Any comments on the pathology? Yes. No. Good one. So we caught a high grade dysplasia with intramucosal cancer. So I mean, one thought would be to make sure that the margin is clear. And I hope that that was already done. And there is a second polyp with a development of low grade dysplasia. So now, questions here, are there any other larger polyps which require resection? Is there coexistent H. pylori, which needs to be eradicated, as well as finding of any synchronous gastric cancer anywhere else in stomach? So the patient did not have H. pylori. The patient was brought back for another endoscopy to remove some additional areas that were smaller than a centimeter on the lesser curve, which showed high grade dysplasia and negative margins on that. And then the patient then also was having additional comorbidities, and the questions about surveillance and risk of endoscopy and need for future endoscopy started becoming at the forefront of the discussion. Any comments on surveillance for gastric? So Madhav, before you answer surveillance, perhaps my question here or concern when I look at this is, yes, this is great that we have removed these four polyps. But then if you look at the rest of the stomach, as Madhav pointed out in his, you know, very nice presentation, I mean, there appears to be background changes in the stomach mucosa, whether it's atrophic gastritis or widespread, you know, gastric intestinal metaplasia. Before we go into surveillance, my concern is, am I missing other areas there? I mean, is our endoscopic evaluation just, are there any tips and tricks for that? Is this a patient, if it's a young patient, should I be considering, you know, surgical therapy or things like that? So those are my questions. Perhaps either Madhav, you or Vani can tell me about that. Just to speak to that, those background changes were not targeted during this endoscopy where the four larger polyps were taken out, but given the histology of those polyps, the subsequent resection was targeting some of that lesser curve, especially that irregular area. And that did show high grade dysplasia. So it speaks to looking and not just focusing only on the size of the raised lesion, but please Dr. Desai. No, I think Dr. Sharma raised a nice point here that, you know, surrounding mucosa and underlying possibility of some sort of syndrome, because this individual has multiple hyperplastic polyps. So there might be a systemic process going on, which requires a separate screening for it. And that will help determine the risk, whether the individual will benefit from annual endoscopy or it will be every three years, at least in the setting of large hyperplastic polyps. I would start with annually, at least if the screening for underlying polyposis syndrome has been done because of the recent history of multiple polyps with several polyps showing, you know, dysplasia, including intramucosal cancer. So initially all the large polyps will require endoscopic removal, followed by, you know, clearance of large polyps and then at least, you know, three year surveillance once that is achieved. And we have some, any additional comments? We have some questions from the audience that I also wanted to get to. Right. Again, in this patient that Vani just presented, so you've removed those polyps and what's your strategy for doing a meticulous examination of the stomach in this situation, besides the washing and everything? Do you routinely use electronic chromoendoscopy? Is there any role for dye spray chromoendoscopy to look for additional lesions again? My concern again is for missing lesions. So how do I get over that? Right. No, that's a great point. And it is not easy, definitely. And so my focus is that in this case is I, you know, initially examined the antrum in a separate, like, you know, time, and then I move on to the corpus because most of the lesions, if they are in antrum, very likely that they have some component of dysplasia or even cancer and systematically kind of doing a withdrawal in the stomach, as you highlighted of at least seven minutes of withdrawal during a standard endoscopy is required to identify pre-cancerous lesions. And you should probably have a block of half an hour or 45 minutes for this patients where you need to do a good exam of the entire stomach, including clearing of bubbles and debris. There is a role of using methylene blue. However, you know, since it will accumulate eventually into the dependent area and you need some sort of expertise, it may be challenging. Similarly, narrowband imaging could be useful with near focus to identify areas where you should be doing sampling, but ultimately this case is required, you know, endoscopy by individuals who have expertise in identifying and removing these lesions. Excellent. And then in terms of resection, do you use cold snare, hot snare for gastric polyps that are greater than a centimeter, but less than two centimeters? Can you describe maybe a little bit about the technique that you recommend? Yes, you know, gastric polyps, especially the setting of chronic inflammation and atrophic gastritis, they are notorious to bleed often. So cold snare has been described and we all use it from time to time for small lesions, especially if you have pointy gland type of polyps, you know, centimeter or so. You can easily remove that with cold snare. But when it comes to hyperplastic polyps, they are of sufficient size. They are vascular. So I prefer using a hot snare and then I examine for any bleeding subsequently. Also be mindful that many times the polyps that you are removing, you are not just removing one polyp. In patients with hyperplastic polyps, they have multiple polyps. And there are pros and cons of leaving a clip in place because they may still stay in place and you will have recurrence of the polyp. And then you might need to remove the clip followed by resection. So plan according to your expertise as well. Yeah, Madhav, good points about that. So one of the challenging cases always, as I mentioned earlier, is, you know, a patient on PPIs with multiple fundigland polyps, right? And the sizes, as you know, range from three millimeters to 12 millimeters, right? They're all over the place and things like that. And according to what you just told us, that if anything is 10 millimeters or greater, even if it's fundigland, needs to be removed. So how many do you remove in one setting? Because, you know, again, some of these just scrape off as you're trying to remove them. You put the snare around it. And even before you close the snare, it's out. And then you're like putting the rod net in or some basket to retrieve it and stuff. So give us some practical tips, Madhav, as to how, you know, when I'm faced with these 20, 30 polyps in a stomach, what should my approach be? Right. Certainly, actually not so rare situation that we all face because nowadays so many individuals are taking PPI forever. So the first point to highlight is kind of similar to antibiotic stewardship is like PPI stewardship. And we need to start talking about that. If we have an individual with multiple fundigland type of polyps, and if there is no concern for FAP or polyposis syndrome, I think first thing to do would be to make sure they really need PPI or not. And that might itself lead to reduction in, you know, some of the polyp size or polyps. Second step would be to make sure that no polyp has any atypical features on your routine exam, routine endoscopy with sampling should be enough. Now, then the question is, are they causing any symptoms? Right. And if they are not causing any symptoms, there is no concern for cancer. Then it's more of a discussion with the patient that larger polyps can be removed for a slightly elevated risk of conversion to cancer in the long run. And in that setting, polyps larger than one to two centimeters can be removed. You can remove like five to 10 polyps in one setting as far as, you know, there is no risk of, you know, thermal injury in same setting, because if there will be bleeding, then next endoscopy will be very difficult to find where exactly that is happening on those 10 polyp sites. Okay. And a few questions on H. pylori. And so the first, do you stop PPI prior to an endoscopy if the plan is to check for H. pylori? Yes. Good question. So, you know, if you already have a patient from the clinic that you have been following up, ideally you want to give at least a break of four to eight weeks. That may or may not happen in all the settings. But again, going back to the point that there should be some sort of PPI stewardship that whether a patient really needs it or not, if you have eradicated H. pylori, ulcer has healed, you might as well stop PPI unless there is another indication. And do you biopsy for H. pylori in a patient with iron deficiency anemia, even if the EGD appears endoscopically normal? Yes. Good point. There is no high certainty of evidence regarding this area. Current American College of Gastroenterology guidelines actually recommend taking or performing H. pylori sampling if iron deficiency anemia is present and no other cause has been found. So certainly a good strategy to look for underlying atrophic gastritis, whether they have autoimmune atrophic gastritis, which could contribute and things like that, rather than just looking for H. pylori. Because as I mentioned, there is a high prevalence even in America now. So you might as well find H. pylori. But you need to be mindful if you are helping the patient with underlying atrophic gastritis or not, and whether that is causing anemia. And Roy Wong has commented, there was a study in Gut from Korea noting a high incidence of gastric cancer in patients with PPIs over six months, even among those with H. pylori eradicated patients. Is this only a phenomenon in Korea? Or should we be careful using PPIs in any form of gastric polyposis? Any comments? Yes. No, good point. So this is something we have been examining for a while now. And guidelines on management of gastrointestinal reflux disease from ACG, AGA, and all of them have actually highlighted this evidence that is coming out now. It requires definitely more closer look. These studies, again, are retrospective linkage studies. They are not prospective studies proving causality. But definitely there is a risk of PPI-induced hypergastronomia. And we question the role of missed H. pylori going undetected for years leading to gastric cancer. It's not proven, but something to be mindful when discussing with the patients. According to meta-analysis of this retrospective studies, there is non-significant pooled risk. But certainly there is a question that we are challenged with. And then can you give us some advice on maybe what we can ask our pathologists to place in the report? So it's one thing for us to take biopsies and place them in two different jars. But what are we looking for in a pathology report that maybe some pathologists might be used to doing and other pathologists aren't? So what's your wish list that you ask for? Yeah. So any time I do, like, you know, I take samples from antrum in one bottle and then corpus in another bottle. In clinical history, I ask the pathologist to comment about presence of CAG and GIM and give me details regarding whether it is complete or incomplete. And that is a bare minimum. Regarding the extensiveness, you will know it after the results are present. And they generally look for H. pylori. So that is given when we ask them to look for CAG. And Vani, good point about this. Both, I think from just, you know, of course, my bias would be the analogies comparing it to Barrett's esophagus, right, in which you want to make sure that just as you're measuring the extent endoscopically in GIM and CAG, I think doing the same thing is endoscopically, where do you see the abnormalities? So again, I think the whole concept for EGD, whether we are dealing with esophagus, stomach, duodenum is, you know, making sure we can make use of your endoscope properly, make use of your chromoendoscopy, virtual chromoendoscopy appropriately. So telling where those biopsies are from, separate jars, and then separate for H. pylori versus the random biopsies or the biopsies, mapping biopsies for GIM that you take. So Vani, excellent points. I think we can all do a better job with it. So I think in terms of time, Vani, we are doing well. What I'd like to do now is just maybe take a very short two-minute break.

gastric polyps

hyperplastic polyps

dysplasia

endoscopic resection

intramucosal carcinoma