A Case of Large Fibrovascular Polyp of the Stomach

Eun Ji Lee; Seung Goun Hong; Hae Ri Baek; Chan Bok Lee; Sang Myung Choi; Sung Jin Kim; Byoung Gy Chae; Cheul Young Choi

doi:10.5946/ce.2013.46.2.186

Articles

Page Path: HOME > Clin Endosc > Volume 46(2); 2013 > Article

Case Report A Case of Large Fibrovascular Polyp of the Stomach: Eun Ji Lee, Seung Goun Hong, Hae Ri Baek, Chan Bok Lee, Sang Myung Choi, Sung Jin Kim, Byoung Gy Chae, Cheul Young Choi; Clinical Endoscopy 2013;46(2):186-188.
DOI: https://doi.org/10.5946/ce.2013.46.2.186
Published online: March 31, 2013

Department of Internal Medicine, SAM Medical Center, Anyang, Korea.

Correspondence: Seung Goun Hong. Department of Internal Medicine, SAM Medical Center, 9 Samdeok-ro, Manan-gu, Anyang 430-733, Korea. Tel: +82-31-467-9114, Fax: +82-31-449-0151, perm@naver.com

• Received: February 14, 2012 • Revised: May 30, 2012 • Accepted: June 20, 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

6,770 Views
44 Download
7 Crossref
6 Scopus

prev next

Full Article

Download PDF

Abstract
INTRODUCTION
CASE REPORT
DISCUSSION
NOTES
REFERENCES

Abstract

A fibrovascular polyp is a rare benign disease of the upper digestive tract and is usually located in the esophagus. To our knowledge, this is the first case of gastric fibrovascular polyp presenting with melena reported in the English literature. The polyp was well visualized on endoscopy and removed with laparoscopic wedge resection. Histology confirmed fibrovascular polyp of the stomach.
Keywords: Fibrovascular; Polyps; Stomach; Melena

INTRODUCTION

Fibrovascular polyp (FVP) is a very rare, intraluminal, submucosal, pedunculated tumor-like lesion which is composed of loose or dense fibrous tissue, adipose tissue, and vascular structures and is covered by normal squamous epithelium.1 In the past, FVP was referred to as lipoma, fibroma, fibrolipoma, fibromyxoma, or fibroepithelial polyp, according to histologic components.2 It generally occurs in middle-aged or elderly males, although some cases have occurred in children, infants, and women.2,3 It occurs mostly in the upper cervical esophagus, hypopharynx, and occasionally in the oropharynx.4,5 However, a report of FVP arising from stomach has not been published. To our knowledge, this case is the first English-written report of a FVP presenting with melena, found under endoscopy and later excised surgically.

CASE REPORT

A 36-year-old male patient visited the emergency room with the chief complaint of melena which began 10 days ago. The patient did not have any medical history, family history, or social history. On his initial visit, his body temperature was 36.5℃, pulse rate was 82 beats per minute, respiratory rate was 18 breaths per minute, and blood pressure was 110/80 mm Hg.

In a physical examination, his conjunctiva was pale, and there was tenderness in his epigastric region with normal bowel sound and no palpable abdominal mass. In a laboratory test, hemoglobin level was 6.7 g/dL and the other findings were within normal limits.

Emergency upper gastrointestinal endoscopy was performed and a pedunculated polyp about 45 mm in diameter, accompanied with ulcer at the base of the polyp, was observed in the gastric antrum. Prominent vascularity with hemorrhagic ulceration on the surface and easy bleeding to light touch with forceps was noted at the proximal side of the lesion, and irregular friable surface with one exposed vessel was noted at the distal side of the lesion (Fig. 1). This was presumed due to thinning or disappearance of swollen gastric mucosa by hemorrhagic, ulcerative change of large submucosal tumor with hypervascular nature. The hemorrhage was controlled with injection of epinephrine followed by thermocoagulation, and intravenous proton pump inhibitor (PPI) and transfusion were started.

In his abdominal computed tomography (CT), about 3.5×5 cm-sized pedunculated mass was located in the lesser curvature of the stomach with partial mucosal wall disruption (Fig. 2). The patient was admitted and observed whether melena persisted. His hemoglobin level, which increased up to the normal value after transfusion, later decreased to 9.7 g/dL and a laparoscopic wedge resection was scheduled for uncontrolled bleeding after failing of endoscopic and supportive managements. Under a laparoscopic exploration, the polyp was located in the lesser curvature of the stomach. The right gastric artery was cut, and wedge resection was performed with a boundary of 4 cm from the margin of the polyp. The surgical specimen was a protruding 4×4×3 cm polyp accompanied with ulcer, and its cross section showed a mucosal lesion in the mixture of gray and yellow colors.

In microscopic findings, overlying gastric mucosa was nearly disappeared and the surface was replaced by exposed submucosal tissue with ulceration and inflammation. The submucosal tissue was composed of many irregular blood vessels, loose connective tissues, and adipose cells that are consistent with FVP (Fig. 3). After the surgery, the patient has been followed up on an outpatient basis until now for about 1 year without any evidence of gastrointestinal bleeding and antral stricture on endoscopy.

DISCUSSION

About 25% of esophageal cases could be missed because of its normal, intact squamous epithelium lining the polyp, especially when the examiner rapidly withdraws the endoscope. Compared to esophageal lesions, gastric submucosal lesions, such as a large pedunculated type like the one in our case, could be clearly seen on endoscopic exam, regardless of the location.2,6 Similarly, in this case, gastrointestinal bleeding was reported in the case of esophageal ulcerated FVP.2 The symptoms of esophageal FVP usually develop when polyp reaches a large size enough to cause dysphagia, substernal discomfort, sensation of mass, and even asphyxiation.1,2,7 In this case, acute blood loss leading to anemia was caused by the ulceration with increased vascularity of large gastric FVP, which was managed surgically due to the risk of constant bleeding.3

FVP is a very rare, slowly growing, malignant transformation, but malignant change has been reported in esophageal polyps.2,3 It is usually presented as a solitary mass, but a case of two synchronous FVP of the hypopharynx has been reported.3

Diagnosis of FVP can be made by a combination of clinical history and various investigations including barium swallow examination, endoscopy, endoscopic ultrasound, CT, and magnetic resonance imaging (MRI).2,8 The differential diagnoses of benign esophageal polyp include leiomyoma, squamous papilloma, and hemangioma.9

The histology of the FVP consists of a mixture of fibrous tissue, adipose tissue, and vascular structures. The proportions of these three components of FVP may vary depending on the lesion and area within the same lesion.10 Various terminologies of FVP, such as fibroepithelial polyp, fibrolipoma, fibromyxoma, lipoma, and fibroma, are all now collectively classified as FVP by World Health Organisation.2

The treatment of choice for FVP is surgical resection. Small polyps less than 2 cm in diameter with a thin pedicle can be removed by endoscopic ligation and electrocoagulation, but care must be taken to ensure that the prominent vessels in the stalk are completely ligated and coagulated.1,2,8 EUS can be a useful adjunct as it provides information on the origin of the stalk and vascularity of the polyp.2 CT and MRI can demonstrate the predominant adipose tissue contents, with respect to fibrovascular tissue, and in such a case, endoscopic treatment may be preferred, especially in older patients with multiple comorbidities.3 A polyp of a diameter of less than 5 cm and no lymph node involvement on abdominal imaging like the one in this case could be an indication for laparoscopic wedge resection, which was performed in our patient.11,12 Although metastasis has never been reported from the polyp, recurrence of resected FVP of the esophagus has been reported, most probably due to incomplete excision of the stalk and residual tissue around the pedicle's base.2,7

In summary, we reported the first case of large gastric FVP presenting with melena. Although recurrent bleeding occurred after endoscopic coagulation and intensive intravenous PPI treatment, the bleeding could be controlled successfully with laparoscopic wedge resection.

The authors have no financial conflicts of interest.

REFERENCES

1. Chourmouzi D, Drevelegas A. Giant fibrovascular polyp of the oesophagus: a case report and review of the literature. J Med Case Rep 2008;2:337.Article PubMed PMC PDF
2. Lee SY, Chan WH, Sivanandan R, Lim DT, Wong WK. Recurrent giant fibrovascular polyp of the esophagus. World J Gastroenterol 2009;15:3697–3700.Article PubMed PMC
3. Ascenti G, Racchiusa S, Mazziotti S, Bottari M, Scribano E. Giant fibrovascular polyp of the esophagus: CT and MR findings. Abdom Imaging 1999;24:109–110.Article PubMed
4. Nuyens MR, Bhatti NI, Flint P. Multiple synchronous fibrovascular polyps of the hypopharynx. ORL J Otorhinolaryngol Relat Spec 2004;66:341–344.Article PubMed
5. Luthen R, Janzik U, Derichs R, Balló H, Ramp U. Giant fibrovascular polyp of the esophagus. Eur J Gastroenterol Hepatol 2006;18:1005–1009.Article PubMed
6. I H, Kim JS, Shim YM. Giant fibrovascular polyp of the hypopharynx: surgical treatment with the biappoach. J Korean Med Sci 2006;21:749–751.Article PubMed PMC
7. Fries MR, Galindo RL, Flint PW, Abraham SC. Giant fibrovascular polyp of the esophagus. A lesion causing upper airway obstruction and syncope. Arch Pathol Lab Med 2003;127:485–487.Article PubMed
8. Yannopoulos P, Manes K. Giant fibrovascular polyp of the esophagus: imaging techniques can localize, preoperatively, the origin of the stalk and designate the way of surgical approach: a case report. Cases J 2009;2:6854.Article PubMed PMC
9. Drenth J, Wobbes T, Bonenkamp JJ, Nagengast FM. Recurrent esophageal fibrovascular polyps: case history and review of the literature. Dig Dis Sci 2002;47:2598–2604.Article PubMed
10. Kim TS, Song SY, Han J, Shim YM, Jeong HS. Giant fibrovascular polyp of the esophagus: CT findings. Abdom Imaging 2005;30:653–655.Article PubMed
11. Lee HH, Hur H, Jung H, Park CH, Jeon HM, Song KY. Laparoscopic wedge resection for gastric submucosal tumors: a size-location matched case-control study. J Am Coll Surg 2011;212:195–199.Article PubMed
12. Ryu KJ, Jung SR, Choi JS, et al. Laparoscopic resection of small gastric submucosal tumors. Surg Endosc 2011;25:271–277.Article PubMed

Fig. 1

Endoscopic findings. (A) It shows about 45 mm-sized poypoid lesion with a short stalk at the base of the antrum. (B) Hemorrhagic ulceration with easy touch bleeding was noted at the proximal side of the lesion and thin, translucent mucosal surface with one exposed vessel was noted at the distal side of the lesion.

Fig. 2

Abdominal computed tomography shows about 3.5×5 cm-sized polypoid mass with marginal enhancement, central inhomogeneous low density, and partial mucosal wall disruption at the anterior wall, lesser curvature of antrum, near the gastric angle (arrows).

Fig. 3

Pathologic findings. (A) Surgical specimen reveals irregular blood vessels with loose connective tissues, chronic inflammatory cells and adipocytes (H&E stain, ×100). (B) Overlying gastric mucosa was nearly disappeared, the surface was replaced by submucosal tissue, and the reactive hyperplastic surrounding gastric mucosa was contiguous to the submucosal lesion (arrows) (H&E stain, ×50).

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

A novel approach to endoscopically manage a large pedunculated polyp obstructing the gastroesophageal junction using a new endoscopic suturing system for endoscopic ligation of the stalk and piecemeal resection
Davekaran Buttar, Mayank Goyal, Ashwariya Ohri, Barham Abu Dayyeh
VideoGIE.2025; 10(5): 240. CrossRef
Large Fibrovascular Polyp at the Lesser Curvature of the Stomach: A Case Report and Literature Review
Huy Q Nguyen, Huy L Phan, Toan K Dang, Hung D Mai, Hien T Tran, Nguyen K Tran Pham
Cureus.2024;[Epub] CrossRef
Results of laparoscopic intragastric surgery
S. Bonnet, V. Basso, A. De Carbonnières, J.-M. Ferraz, A. Blain, B. Gayet, D. Fuks
Journal of Visceral Surgery.2021; 158(6): 469. CrossRef
Résultats de la résection intra-gastrique laparoscopique
S. Bonnet, V. Basso, A. de Carbonnières, J.-M. Ferraz, A. Blain, B. Gayet, D. Fuks
Journal de Chirurgie Viscérale.2021; 158(6): 513. CrossRef
Giant fibroepithelial polyp of the thigh and retroperitoneal fibromatosis in a young woman: a rare case
Ruchi Gupta, Shuchi Smita, Ruchi Sinha, Neetu Sinha, Lakshmi Sinha
Skeletal Radiology.2018; 47(9): 1299. CrossRef
A Case of Fibrovascular Polyp of the Stomach: Sonographic and Computed Tomographic Findings
Yun Kyung Shin, Hyun Cheol Kim, Dal Mo Yang, Sang Won Kim, Sun Jung Rhee, Jong Soo Shin, Kyu Yeoun Won
Iranian Journal of Radiology.2016;[Epub] CrossRef
Giant fibrovascular polyp in the hypopharynx: a case report and review of the literature
Mineko Oka, Rumi Ueha, Takaharu Nito, Tatsuya Yamasoba
SpringerPlus.2016;[Epub] CrossRef

PubReader
ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

A Case of Large Fibrovascular Polyp of the Stomach

Clin Endosc. 2013;46(2):186-188. Published online March 31, 2013

DOI: https://doi.org/10.5946/ce.2013.46.2.186

XML Download

Figure

A Case of Large Fibrovascular Polyp of the Stomach

Fig. 1 Endoscopic findings. (A) It shows about 45 mm-sized poypoid lesion with a short stalk at the base of the antrum. (B) Hemorrhagic ulceration with easy touch bleeding was noted at the proximal side of the lesion and thin, translucent mucosal surface with one exposed vessel was noted at the distal side of the lesion.

Fig. 2 Abdominal computed tomography shows about 3.5×5 cm-sized polypoid mass with marginal enhancement, central inhomogeneous low density, and partial mucosal wall disruption at the anterior wall, lesser curvature of antrum, near the gastric angle (arrows).

Fig. 3 Pathologic findings. (A) Surgical specimen reveals irregular blood vessels with loose connective tissues, chronic inflammatory cells and adipocytes (H&E stain, ×100). (B) Overlying gastric mucosa was nearly disappeared, the surface was replaced by submucosal tissue, and the reactive hyperplastic surrounding gastric mucosa was contiguous to the submucosal lesion (arrows) (H&E stain, ×50).

Fig. 1

Fig. 2

Fig. 3

A Case of Large Fibrovascular Polyp of the Stomach