Upper Gastrointestinal Tract Polyps: What Do We Know About Them?

Upper gastrointestinal tract (GIT) polyps are usually asymptomatic. However, they may cause symptoms such as dyspepsia, bleeding, anemia, abdominal pain and gastric outlet obstruction. During endoscopic procedures, they are usually observed at an incidence rate of 2-3%. Their incidence rate in general population is rather low at less than 1% (Feldman et al., 2010). The most frequent localization in the stomach appears to be the antrum (58.8%) (Yoon et al., 2006). Upper GIT polyps can be seen with synchronic or metachronic colon polyps (Hirota et al., 2006). The majority of gastric polyps (70-90%) are hyperplastic or fundic gland polyps. Hyperplastic and adenomatous polyps are more prevalent in areas where HP infection is common (Archimandritis et al., 1996; Morais et al., 2007). On the other hand, fundic gland polyps are more common in regions of HP eradication (Jalving et al., 2006; Carmack et al., 2009). The presence of H pylori infection is closely related to chronic gastritis which significantly increases the risk of developing peptic ulcer, gastric adenocarcinoma an gastric mucosa-associated


Introduction
Upper gastrointestinal tract (GIT) polyps are usually asymptomatic. However, they may cause symptoms such as dyspepsia, bleeding, anemia, abdominal pain and gastric outlet obstruction. During endoscopic procedures, they are usually observed at an incidence rate of 2-3%. Their incidence rate in general population is rather low at less than 1% (Feldman et al., 2010). The most frequent localization in the stomach appears to be the antrum (58.8%) (Yoon et al., 2006). Upper GIT polyps can be seen with synchronic or metachronic colon polyps (Hirota et al., 2006). The majority of gastric polyps (70-90%) are hyperplastic or fundic gland polyps. Hyperplastic and adenomatous polyps are more prevalent in areas where HP infection is common (Archimandritis et al., 1996;Morais et al., 2007). On the other hand, fundic gland polyps are more common in regions of HP eradication (Jalving et al., 2006;Carmack et al., 2009). The presence of H pylori infection is closely related to chronic gastritis which significantly increases the risk of developing peptic ulcer, gastric adenocarcinoma an gastric mucosa-associated
Gastric adenomatous polyps have potential for malignancy. It was reported that about 11% of such polyps developed into carcinoma in situ within 4 years of followup (Feldman et al., 2010). After excision, the recurrence rate is 16% (Hirota et al., 2006).
The purpose of this study was to examine the relationships between demographic characteristics of patients with upper gastrointestinal polyps and localization, histopathological types, HP infection, as well as changes in gastric mucosa and the rate of malignant development, with reference to the current information found in the literature.

Materials and Methods
We conducted a retrospective analysis on the data regarding 59 patients with polyps [37 females and 22 males with a mean age of 66.79 years, (ranging from 35 to 89 years)] which were detected during routine upper gastrointestinal endoscopy (55,987 tests) performed at the endoscopy unit of Istanbul Education and Research Hospital between January 2006 and June 2012. A total of 66 polyps retrieved from these patients with polypectomy were analyzed in terms of their localization, histopathological characteristics, changes that occurred in gastric mucosa, their relationship with HP infection, and rate of malignant transformation.
All endoscopic procedures were performed with Midazolam (IV) and sedation. The polyps were resected with application of cautery through a snare or biopsy forceps. In addition, at least two antral biopsy specimens were collected from all patients undergoing polypectomy.
In cases with fundic gland polyps, no intestinal metaplasia was detected, while this type was more common in older age groups. 39.02% of the patients with hyperplastic polyps had intestinal metaplasia. HP incidence was significantly higher in patients with hyperplastic polyps than in those with fundic gland polyps. In 56.09% of cases with hyperplastic polyposis, chronic atrophic gastritis was present. In 3 patients diagnosed with neuroendocrine neoplasia, chronic atrophic gastritis and intestinal metaplasia were observed in the stomach. However, they had no HP infection.
The demographic data of the patients with polyps, histological types, gastric mucosa and their relationship with HP infection are summarized in Table 1.

Discussion
Gastric polyps are histologically classified as hyperplastic, adenomatous or inflammatory polyps. The incidence of gastric polyps detected with endoscopic procedures has been reported to range from 2 to 6% (Carmack et al. 2009;. Accounting for 80% of cases, hyperplastic polyps derive from the tissues lining the inner surface of the stomach, and they are not true neoplasms. There is no connection between these polyps and gastric carcinoma. Further endoscopic monitoring is not indicated in hyperplastic polyps. However, hyperplastic polyps are more likely to coexist with atrophic gastritis, which is generally considered to have precancerous potential. Approximately 10% of adenomatous polyps contains malignant foci called adenocarcinoma. In addition, 20% of the patients with benign adenomatous polyps have been reported to have a malignant cancer in another part of their stomach. The incidence of cancer in adenomatous polyps tends to be higher as the size of the polyp increases. Pedunculated lesions smaller than 2 cm in diameter are not usually malignant. Roughly 10% of the benign adenomatous polyps may show malignant transformation therefore endoscopic monitoring of patients is recommended after these polyps have been removed by polypectomy (Kokkola et al., 1998;Oberhuber and Stolte, 2000;Mansour-Ghanaei et al., 2013).
The incidence of polyps and histopathological types vary between geographical regions. A retrospective study examining gastric polyps reported that patients diagnosed with gastric polyps ranged from 22 to 87 years of age, while patients over the age of 60 had an increased likelihood of multiple polyps. In this study, the most common type of polyps were hyperplastic polyps (70%) (Archimandritis et al., 1996).
Hyperplastic polyps are usually associated with HP infection and atrophic gastritis. Hyperplastic and adenomatous polyps are known to be more prevalent in geographical regions where HP infection is common, as compared with fundic gland polyps (Morais et al., 2007). HP infection was found to be protective against the development of fundic gland polyps. Patients with fundic gland polyps were reported to have a low incidence rate of HP infection (Carmack et al. 2009). There are also studies showing that HP eradication therapy may lead to regression of hyperplastic polyps (Ljubicic et al.,1999;Ohkusa et al., 1998). In our study, 39.02% of the patients with hyperplastic polyps were diagnosed with intestinal metaplasia. HP incidence was found to be significantly higher in patients with hyperplastic polyps than in those with fundic gland polyps.Also three patients had  DOI:http://dx.doi.org/10.7314/APJCP.2015.16.7.2999 noroendocrine neoplasia.
In conclusion, hyperplastic polyps are the most common polyps seen in the upper gastrointestinal tract. In cases with hyperplastic polyps, the incidence of HP infection and concomitant chronic atrophic gastritis and intestinal metaplasia is higher. Faveolar hyperplasia is the second most common and can be regarded as a precursor of hyperplastic polyps. Multiple polyps are more prevalent in patients over age 60, with an increased cancer rate.