Sessile Polyps in the Sphincteric Cylinder #

A number of gastric lesions may present as polyps; however, the term polyp is usually used to indicate a benign epithelial tumor (Marshak and Lindner l97l).

In 2420 double-contrast radiographic studies of the stomach Gordon et al (l980) encountered polyps in 38 (1.6 %). Most were of an inflammatory or hyperplastic nature; none was associated with gastric malignancy. Solitary polyps tended to occur in the "antrum", while multiple polyps (usually 2 or 3) were more often located in the gastric fornix and body. Two-thirds were less than 1.0cm in diameter, only one being larger than 2.0cm; most were sessile and could not be removed by a snare. The surrounding mucosa was either normal or showed evidence of acute or chronic gastritis. However, Laxen et al (l983), in a study of 183 patients with gastric polyps, found epithelial dysplasia and increased prevalence of intestinal metaplasia in most.

The following case shows interesting features:

Case Report #

Case 36.1. W.V.W., 46 year old male, presented with vague upper abdominal symptoms. Cholecystectomy had been done 3 years previously. Radiographic examination showed a round, polyp-like lesion 1.5cm in diameter and surrounded by a circular mucosal fold, in the centre of the pyloric sphincteric cylinder (Fig 36.1A). Cyclical contractions of the cylinder were normal; during contraction the polyp moved in an orad direction, and with maximal contraction it was located approximately 2.0cm more orally (Fig 36.1B). Gastroscopy confirmed the presence of a benign, sessile polyp; histologically the mucosa was normal. At gastrostomy the polyp could not be located. Follow-up radiography and gastroscopy 3 years later showed it to be unchanged.

A

B

Fig. 36.1 A,B. Case W.V.W. A Round, sessile, benign polyp (arrowed) in centre of pyloric sphincteric cylinder. B Near maximal contraction of sphincteric cylinder. The polyp (arrowed) has moved in an orad direction

In a case of Peutz-Jeghers syndrome, a pair of sessile mucosal polyps in the pyloric sphincteric cylinder also moved in an orad direction during contraction of the cylinder.

Peutz-Jeghers Syndrome #

The three salient features of this syndrome are polyp formation in the gastrointestinal tract, mucocutaneous melanin pigmentation and inheritance through an autosomal dominant gene (Morson and Dawson l979). The polyps, which are hamartomas, are most common in the small bowel, but not infrequently occur in the stomach and colon. The condition usually presents in childhood with attacks of recurrent colic due to intussusception caused by the small bowel polyps, or it may present as iron deficiency anaemia due to haemorrhage. Macroscopically the polyps may be sessile but not infrequently they are pedunculated with short, broad pedicles (Morson and Dawson l979). Microscopically there is proliferation of the muscularis mucosae to form a branching pattern, clothed with essentially normal gastric mucosa.

The following case is an example:

Case Report #

Case 36.2. A.P., girl aged 16 years, was admitted with a history of recurrent malaena (for which blood transfusions had been necessary) and symptoms of iron deficiency anaemia. On examination hyperpigmented "freckles" were seen around the mouth, on the buccal mucosa and on the fingers and feet. (Her father had similar areas of pigmentation). Other findings were a hypochromic microcytic anaemia and sedimentation rate of 20.0 mm/hr. Rectal examination revealed no abnormality but tests for stool occult blood were positive. Radiological examination showed two round, polypoid defects, each l.5cm in diameter, within the confines of the pyloric sphincteric cylinder (Fig 36.2A). The distal margins of the defects were 1.0 and 3.0cm respectively from the pyloric aperture; no stalks were seen. During contraction of the cylinder the defects moved in an orad direction, the distance from their distal margins to the pylorus increasing to 4.0cm and 5.2cm respectively (Fig 36.2B). These movements occurred regularly during the examination.

Fig. 36.2 Case A.P. Peutz-Jeghers syndrome. A Sessile polyps close to pyloric aperture in relaxed pyloric sphincteric cylinder.

Fig. 36.2 B.Sphincteric cylinder contracted. The polyps have moved in an orad direction

A number of polyps were also seen in the second and third parts of the duodenum, at the duodeno-jejunal junction and in the upper jejunum. A double-contrast barium enema examination revealed no abnormality in the colon.

At endoscopy the presence of 2 sessile prepyloric mucosal polyps was confirmed. In addition 2 smaller but similar polyps were seen in the body of the stomach; none of the polyps had a stalk. Because of technical complications biopsies were not done. A clinical and radiological diagnosis of Peutz-Jeghers syndrome was made. While under investigation symptoms of upper small bowel obstruction supervened, necessitating a laparotomy. A jejuno-jejunal intussusception was found and reduced. Gastrostomy, duodenostomy and jejunostomy were done at which polyps were removed from the stomach, duodenum and jejunum.

The histology of the gastric polyps showed prominent, branching processes of muscularis mucosae with overlying columnar cell epithelium, without evidence of dysplasia. The diagnosis of hamartomatous polyps of the Peutz-Jeghers type was made. The patient made an uneventful recovery.

Discussion #

It is not unusual for pedunculated polyps in the pyloric sphincteric cylinder to be extruded into the duodenum. Consequently they may be visualized either in the pyloric region of the stomach or in the duodenum at a single radiographic examination.

The 2 cases described here had sessile polyps on the mucosa of the sphincteric cylinder. During contraction of the latter the polyps moved in an orad direction, and with maximal contraction were clearly situated farther from the pyloric aperture than in the partially contracted or non-contracted phases. This seems to confirm the fact that the pyloric mucosa may move in an orad direction during contraction of the sphincteric cylinder, a phenomenon first described by Golden (l937) (Chap 13).

References #

1. Golden R. Antral gastritis and spasm. J Amer Med Assoc l937, 109, 1497-1500.
2. Gordon R, Laufer I, Kressel HY. Gastric polyps found on routine double-contrast examination of the stomach. Radiology l980, 134, 27-30.
3. Laxen F, Kekki M, Sipponen P, et al. The gastric mucosa in stomachs with polyps: morphologic and dynamic evaluation. Scand J Gastroenterol l983, l8, 503-511.
4. Marshak RH, Lindner AE. Polypoid lesions of the stomach. Sem Roentg l97l, 6, 151-167.
5. Morson BC, Dawson IMP. Gastrointestinal Pathology, 2nd ed, Blackwell Scientific Publications, London l979, p 82.