Gastrointestinal polypoid lesions: a poorly known endoscopic feature of portal hypertension

Abstract

Aim: To describe a poorly known endoscopic entity associated with portal hypertension, characterized by polypoid lesions either in the stomach or small intestine of patients with cirrhosis.

Methods: Between 2003 and 2012, patients with cirrhosis and portal hypertension underwent endoscopic workup of portal hypertension in our endoscopy unit. The clinical expression, endoscopic features of these lesions, and their pathological characteristics are described.

Results: A total of 1538 patients were included, among which 14 (0.9%) presented polypoid lesions; these patients had evidence of portal hypertension and had dilated capillaries in the lamina propria. Four patients presented with severe anaemia or melaena and required treatment. Propranolol was administered to three patients, and one patient needed a transjugular intrahepatic portosystemic shunt in order to control bleeding. For asymptomatic patients in whom polypoid lesions were resected, no recurrence of lesions was observed during follow-up gastroscopy (median 36 months, range 7-85 months).

Conclusion: Portal hypertension-associated gastric or small intestine polypoid lesions may be associated with a significant risk of bleeding and are responsive to adequate treatment of portal hypertension.

Keywords: Anaemia; capsule endoscopy; cirrhosis; polyps; small bowel.

Figure 1.

Patient 1: severe anaemia and recurrent episodes of melaena. (A) Terminal ileoscopy revealed one polypoid lesion with a mosaic pattern of mucosa around the base and multiple red bump lesions. (B–D) Videocapsule endoscopy performed in the same patient showed diffuse small intestinal involvement by sparse red bump lesions (B) and confirmed the presence of the polypoid lesion in the terminal ileum (C, D). (E) Biopsy specimen of the ileal polyp; numerous vascular dilations in the lamina propria are suggestive of hypertensive enteropathy; some capillaries presented intravascular fibrin thrombi, a feature well described in gastric antral vascular ectasia. (F) Terminal ileoscopy performed 5 months after treatment with β-blockers revealed significant regression of the red bumps and polypoid lesions previously described in the terminal ileum whereas the patient no longer exhibited melaena or anaemia.

Figure 2.

Patient 12: chronic melaena and severe anaemia requiring multiple transfusions. (A) EGD revealed multiple red bumps in the duodenum. (B, C) Videocapsule endoscopy demonstrated multiple red bumps also present in the jejunum (B) and ileum, with a mosaic-like pattern in the surrounding mucosa (C).

Figure 3.

(A) Patient 4: multiple pediculated polyps in the antrum presenting whitish exudates at their top; several of these polyps were safely removed by snare polypectomy using endocut current. (B) Patient 6: one isolated sessile polyp in the antrum, with a discrete whitish exudate at its top. (C) Patient 5: upper GIE revealed multiple polypoid lesions in the duodenum. (D) Patient 7: histological examination of antral polyp; numerous vascular dilations in the lamina propria, suggesting portal hypertensive enteropathy.

Figure 4.

Patient 8: one large pediculated polyp in the antrum diffusely covered by a whitish exudate; this large polyp was safely removed by polypectomy after leaving an endoloop around its base.

Figure 5.

Patient 13: A NAFLD cirrhotic patient underwent a gastroscopy for portal hypertension work-up. (A,B) A polypoid lesion in the pylorus observed during gastroscopy (A) was resected with a snare and endocut current (B); the endoscopic pattern of the polyp was that of an orange-coloured lesion with slightly whitish exudates at the top. (C) Histological examination of this polyp; numerous vascular dilations in the stroma separated by inflammatory infiltrates comprising neutrophils and eosinophils.