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Fundic Gland Polyp

Definition

  • Polyp occurring in the body/fundus of the stomach characterized by dilation of the fundic glands

Alternate/Historical names:

  • Cystic hamartomatous gastric polyp
  • Elster’s glandular cysts
  • Fundic gland hyperplasia

Diagnostic Criteria

  • Sessile polyp of the gastric fundus/body
    • May be multiple
    • Usually small <1 cm
  • Histologically identical polyps with varying clinical presentations
    • Sporadic
      • Usually an incidental finding
    • Familial adenomatous polyposis
      • Present in about half of FAP patients
    • Following treatment with proton pump inhibitors (PPI)
      • Increased risk x 4
      • Increases with time
      • Frequently multiple
    • Rare sporadic non-FAP polyposis
      • Defined as ≥10 polyps
      • Non-familial
  • Irregular proliferation of deep fundic glands
    • Multiple budding from the glands
    • Overlying pits shortened
  • Cystic dilation of glands
    • Lining must include chief and parietal cells
    • May include foveolar mucous cells
  • Smooth muscle may surround cysts
    • Long thin bundles
    • Extend from muscularis mucosae to superficial lamina propria
  • Scant stromal inflammation
  • Focal dysplasia may occur in polyps of FAP patients (40%)
    • Rare in other patients (3%)
  • Carcinoma develops rarely in North American FAP patients with fundic gland polyps
    • Marginally, if at all, increased above the general population
    • Rare cases suggest origin from within a fundic gland polyp
    • Carcinoma is much more frequent in Japan and Korea
      • Up to 10x increase over general population
      • No increased risk of carcinoma in non-FAP patients

    Robert V Rouse MD
    Department of Pathology
    Stanford University School of Medicine
    Stanford CA 94305-5342

    Original posting/updates : 11/29/09, 11/13/11

Supplemental studies

Genetic studies

  • PCR demonstrates mutations in most cases studied
    • FAP cases have a second somatic mutation in APC
    • Sporadic cases, including sporadic polyposis, have mutations in beta-catenin
      • Individual polyps in the same patient may have different mutations
    • No data on PPI associated cases
    • Not generally necessary for diagnosis

Differential Diagnosis

Small fundic gland polyps may be mistaken for normal gastric fundus
    • Polypoid nature may not be evident
    • Distortion of glands may not be evident
    • Endoscopic description of fundic polyp(s) may suggest the diagnosis
    • History of FAP or PPI should suggest the diagnosis
    • Identification of even mild cystic dilation of deep glands lined by parietal and chief cells should permit the diagnosis

 

Fundic Gland Polyp Focal Foveolar Hyperplasia
Scant stroma, no inflammation Prominent edematous inflamed stroma
Cysts lined by parietal and chief cells Cysts lined my foveolar mucous cells
Increase in deep fundic glands forms the polyp Primarily elongation of pits

 

Fundic Gland Polyp Juvenile Polyposis
Scant stroma, no inflammation Prominent inflamed stroma
Cysts lined by parietal and chief cells Cysts lined by mucous cells
No association with polyps in the colorectum Most cases involve the colorectum
Same differential applies to the polyps of Cowden disease and Cronkhite-Canada syndrome

 

Fundic Gland Polyp Peutz-Jeghers Syndrome
Thin bundles of smooth muscle may surround cysts Arborizing muscle in polyps surrounds lobules of glands
Frequent cystic dilation Cystic dilation not prominent
No polyps in small intestine Most polyps in small intestine
Not familial Autosomal dominant
Beta-catenin or APC mutations LKB1/STK11 mutations in 50-90%

 

Fundic Gland Polyp Menetrier Disease
Increase in deep fundic glands forms the polyp Deep fundic glands are atrophic
Surface pits are shortened Foveolar hyperplasia forms the thickened mucosa

Bibliography

  • Noffsinger A, Fenoglio-Preiser CM, Maru D, Gilinisky N.  Gastrointestinal Diseases, AFIP Atlas of Nontumor Pathology, First Series, Fascicle 5, 2007.
  • Bosman FT, Carneiro F, Hruban RH, Thiese ND (Eds). WHO Classifiication of Tumors of the Digestive System, IARC, Lyon 2010
  • Park YD, Lauwers GY. Gastric polyps: classification and management. Arch Pathol Lab Med. 2008 Apr;132(4):633-40.
  • Oberhuber G, Stolte M. Gastric polyps: an update of their pathology and biological significance. Virchows Arch. 2000 Dec;437(6):581-90.
  • Jalving M, Koornstra JJ, Wesseling J, Boezen HM, DE Jong S, Kleibeuker JH. Increased risk of fundic gland polyps during long-term proton pump inhibitor therapy. Aliment Pharmacol Ther. 2006 Nov 1;24(9):1341-8.
  • Torbenson M, Lee JH, Cruz-Correa M, Ravich W, Rastgar K, Abraham SC, Wu TT. Sporadic fundic gland polyposis: a clinical, histological, and molecular analysis. Mod Pathol. 2002 Jul;15(7):718-23.
  • Odze RD, Marcial MA, Antonioli D. Gastric fundic gland polyps: a morphological study including mucin histochemistry, stereometry, and MIB-1 immunohistochemistry. Hum Pathol. 1996 Sep;27(9):896-903.
  • Goodman AJ, Dundas SA, Scholefield JH, Johnson BF. Gastric carcinoma and familial adenomatous polyposis (FAP). Int J Colorectal Dis. 1988 Nov;3(4):201-3.
  • Will OC, Man RF, Phillips RK, Tomlinson IP, Clark SK. Familial adenomatous polyposis and the small bowel: a loco-regional review and current management strategies. Pathol Res Pract. 2008;204(7):449-58.
  • Abraham SC, Nobukawa B, Giardiello FM, Hamilton SR, Wu TT. Sporadic fundic gland polyps: common gastric polyps arising through activating mutations in the beta-catenin gene. Am J Pathol. 2001 Mar;158(3):1005-10.
  • Sekine S, Shibata T, Yamauchi Y, Nakanishi Y, Shimoda T, Sakamoto M, Hirohashi S. Beta-catenin mutations in sporadic fundic gland polyps. Virchows Arch. 2002 Apr;440(4):381-6.
  • Zelter A, Fernández JL, Bilder C, Rodríguez P, Wonaga A, Dorado F, Galich M, Viola LA. Fundic gland polyps and association with proton pump inhibitor intake: a prospective study in 1,780 endoscopies. Dig Dis Sci. 2011 Jun;56(6):1743-8
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