Management of Polypoidal Lesions in the Fundus of the Stomach
Polypoidal lesions in the fundus of the stomach should be biopsied for histopathological assessment and completely resected when they are >1 cm, pedunculated, or symptomatic, with the management approach determined by the specific histological type. 1
Initial Assessment and Documentation
- Document the following characteristics of the polyp(s):
- Number (or estimated number if numerous)
- Location within the stomach
- Size of the largest polyp
- Morphology (sessile vs. pedunculated)
- Surface characteristics
- Obtain photographic documentation of all polyps or representative polyps if numerous 1
- Biopsy all gastric polyps other than fundic gland polyps (FGPs) for histopathological assessment 1
Management Based on Histological Type
1. Fundic Gland Polyps (FGPs)
- Most common in the fundus (13-77% of all gastric polyps)
- Endoscopic appearance: pale, smooth, glassy, transparent/translucent
- Management:
- No excision required unless they have atypical features
- Excision indicated if: >1 cm, antral location, ulceration, or unusual appearance
- Re-evaluate long-term PPI use as FGPs can regress when PPIs are stopped
- No surveillance needed except in FAP syndrome 1
2. Hyperplastic Polyps
- Constitute 18-70% of gastric polyps
- Endoscopic appearance: smooth, red with whitish exudates, dome-shaped
- Management:
- Resect if >1 cm, pedunculated, or symptomatic (causing obstruction, bleeding)
- Test for H. pylori and eradicate if present before re-evaluation for endoscopic therapy
- Assess background mucosa for gastric atrophy, intestinal metaplasia, and synchronous neoplasia 1
- Careful follow-up as these polyps can harbor dysplasia (1.9-19%) and malignant transformation 2
3. Adenomatous Polyps
- Usually single (82%), small (<2 cm), located in antrum and incisura angularis
- High risk of progression to cancer (50% of adenomas >2 cm contain foci of adenocarcinoma)
- Management:
- Complete resection is mandatory when clinically appropriate and safe
- En bloc excision with ESD is advisable for sessile polyps >15 mm
- Follow-up gastroscopy at 6-12 months after resection
- Annual surveillance thereafter 1
4. Gastric Squamous Papilloma
- Complete endoscopic resection recommended even without dysplastic changes
- Test for H. pylori as chronic mucosal irritation may be associated with papilloma development 3
Endoscopic Resection Techniques
- For polyps <2 cm: Snare polypectomy or endoscopic mucosal resection (EMR)
- For sessile polyps >15 mm: Endoscopic submucosal dissection (ESD) preferred to reduce recurrence risk 1
- For pedunculated polyps: Snare polypectomy after submucosal injection of diluted adrenaline solution 4
Follow-up Recommendations
- For adenomas: Follow-up gastroscopy at 6-12 months after endoscopic resection, then yearly intervals 1
- For hyperplastic polyps: Follow-up interval determined by the stage of chronic atrophic gastritis
- For FGPs: No routine follow-up needed unless in FAP syndrome 1
Special Considerations
- Enhanced endoscopic imaging (NBI, i-Scan, FICE) should be used when there is diagnostic uncertainty following white light examination 1
- Symptomatic polyps causing gastric outlet obstruction require prompt removal 2, 4
- Always evaluate the surrounding mucosa for H. pylori, gastric atrophy, and intestinal metaplasia, as these conditions may influence management and follow-up strategies 1
Remember that complete endoscopic resection serves both diagnostic and therapeutic purposes, providing definitive histopathology while also achieving radical treatment 4.