Teaching Case

A 60-year-old male presented with a history of pain abdomen and early satiety for 3 months. He gave no history of diarrhoea or constipation.

Lab investigations were unremarkable.

Patient was referred to radiology department for further investigation.

Patient was worked up with single contrast barium study, ultrasonography and contrast-enhanced Computer tomography (CT) of abdomen.

Single contrast barium study showed a lobulated filling defect involving the body of the stomach. Contrast passage was seen between the lobulations. However, barium opacification was noted in antrum and pyloric region with distal passage of contrast (Figure 1).

Ultrasound showed a heterogeneous lesion with multiple lobulated components, forming a conglomerate mass, with a linear hyperechoic area noted in stomach lumen (Figure 2,3).  On colour doppler, the lesion showed vascularity at linear hyperechoic area and a vessel was seen traversing through the lesion with normal blood flow (Figure 4).

CT unenhanced imaging showed an intraluminal exuberant soft tissue density lesion with lobulated surface arising from body, antrum and predominantly greater curvature of stomach largest measuring approximately 11 x 4 cm (length x thickness) (Figure 5). On post-contrast study, the lesion showed homogeneous enhancement. There was no evidence of exophytic extension or peri gastric fat stranding or abdominal lymphadenopathy (Figure 6,7).

Upper gastrointestinal endoscopy showed a mass lesion arising from greater curvature with overlying smooth mucosa (Figure 8a, b).

 Mucosal biopsy was taken and histopathology revealed a hyperplastic polyp.

Between 85% and 90% of all neoplasms in the stomach and duodenum are benign. [1] About 50% are mucosal lesions and 50% are submucosal. Most of these benign neoplasms are discovered fortuitously on radiologic or endoscopic studies performed for other reasons. Occasionally, however, tumours that are large or ulcerated may cause abdominal pain or upper gastrointestinal (GI) bleeding. Depending on their histologic features, some benign tumours are also important because of an associated risk of malignancy.

Hyperplastic polyps are the most common benign epithelial neoplasms in the stomach, comprising 75% to 90% of all gastric polyps. [2] Because hyperplastic polyps are not premalignant, they must be differentiated from adenomatous polyps, which have Appearance: known risk of malignant degeneration

Hyperplastic polyps that are lobulated or are larger than 1 cm in size cannot be distinguished from adenomatous polyps in the stomach. Rarely, giant hyperplastic polyps or a conglomerate mass of hyperplastic polyps can mimic a polypoid gastric carcinoma. [3,4] Thus, polyps that are unusually large or lobulated should be evaluated by endoscopy and biopsy and, if necessary, resected for a definitive diagnosis.

The differential diagnosis for multiple hyperplastic polyps in the stomach includes multiple adenomatous polyps and gastric involvement by one of the polyposis syndromes. However, adenomatous polyps tend to be larger and less numerous and are more lobulated than most hyperplastic polyps. Both types of polyps can occur simultaneously in some patients, [3] but an adenomatous polyp should be suspected if one lesion is disproportionately larger than the others. [5] A generalized polyposis syndrome should be suspected if multiple polyps are also present in the small bowel or colon.

 In our case, following prompt radiological diagnosis and histopathologic confirmation of the nature of the lesion, the patient was advised surgery. However, patient refused surgery due to personal reasons. He was then advised to be under regular close follow up.

Written informed patient consent for publication has been obtained.