What is the best initial step in managing a patient with gastric polyps that are thought to be caused by calcium supplementation?

Management of Calcium-Induced Gastric Polyps

Initial Management Step

The best initial step is to re-evaluate the appropriateness of calcium supplementation and consider discontinuation or dose reduction, as calcium-induced fundic gland polyps are associated with chronic calcium use and may regress when supplementation is stopped. 1

Understanding Calcium-Induced Gastric Polyps

Calcium supplementation, like proton pump inhibitors, is associated with fundic gland polyps (FGPs), which are now the most common gastric polyps in Western countries. 2 These polyps typically:

• Present as multiple small polyps in the gastric fundus 1
• Are characterized by small round pits and a honeycomb microvascular pattern on optical enhancement 3
• Have a very low malignancy risk when <1 cm (1.9% dysplasia risk, 1.9% cancer risk) 1

Size-Based Management Algorithm

For Polyps <1 cm (Most Common Scenario)

• No resection is required for typical fundic gland polyps <1 cm 1
• Discontinue or reduce calcium supplementation if clinically appropriate 1
• Document the number, size, location, and morphology of all polyps 1
• Evaluate the entire stomach for synchronous neoplasia and assess background mucosa for H. pylori, gastric atrophy, and gastric intestinal metaplasia 1

For Polyps ≥1 cm or Atypical Features

Complete resection is mandatory if any of the following are present: 1

• Polyp size >1 cm (due to increased dysplasia and cancer risk)
• Antral location (atypical for FGPs, suggests alternative diagnosis)
• Ulceration or unusual appearance
• Symptomatic polyps causing obstruction or bleeding

Critical Diagnostic Considerations

Rule Out Alternative Diagnoses

When polyps are attributed to calcium supplementation, confirm they are truly fundic gland polyps and not:

• Hyperplastic polyps (25% associated with H. pylori gastritis, require different management with H. pylori testing and treatment) 4, 5
• Adenomatous polyps (30% have synchronous gastric adenocarcinoma, 50% of adenomas >2 cm contain foci of adenocarcinoma) 3, 6

Use Optical Enhancement for Accurate Diagnosis

• Apply NBI, i-Scan, or FICE to improve diagnostic accuracy 1
• FGPs show small round pits and honeycomb microvascular pattern (sensitivity 94.7%, specificity 97.4%) 3
• Polyps with same or lighter color than background mucosa with no vessels or isolated lacy vessels are FGPs in 97-100% of cases 3

Surveillance Strategy

For typical FGPs <1 cm with no dysplasia: No routine surveillance is required after calcium discontinuation 1

Surveillance endoscopy is only indicated if: 1, 4

• Dysplasia is found on histology
• Gastric atrophy or gastric intestinal metaplasia is present
• Surveillance intervals should be determined by the stage of chronic atrophic gastritis, not the polyps themselves

Critical Pitfalls to Avoid

• Do not assume all small polyps are benign without proper characterization, as size >1 cm significantly increases dysplasia and cancer risk across all polyp types 1
• Always evaluate for familial adenomatous polyposis (FAP) in patients with >20 fundic gland polyps, age <40 years with multiple polyps, or presence of duodenal adenomas 1
• Do not confuse fundic gland polyps with hyperplastic polyps, which require H. pylori testing and have different management algorithms 6
• Avoid overlooking the surrounding gastric mucosa, as synchronous neoplastic lesions can be present and require different management 4