MKSAP Quiz: Follow-up of fundic gland polyps
A 55-year-old man is evaluated for follow-up of fundic gland polyps. After endoscopy and biopsy showing no dysplasia, when should a follow-up upper endoscopy be performed?
A 55-year-old man is evaluated for follow-up of fundic gland polyps. Upper endoscopy was performed to screen for Barrett esophagus; it revealed a normal esophagus and approximately 10 to 15 polyps with a similar appearance in the gastric body (1-8 mm). Multiple biopsy specimens revealed fundic gland polyps without dysplasia. His only medication is omeprazole. Findings on colonoscopy are normal.
When should follow-up upper endoscopy be performed?
A. 1 year
B. 3 to 5 years
C. 10 years
D. No follow-up endoscopy
MKSAP Answer and Critique
The correct answer is D. No follow-up endoscopy. This content is available to MKSAP 19 subscribers as Question 72 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The patient does not require follow-up upper endoscopy (Option D). Fundic gland polyps are the most common benign epithelial gastric polyp incidentally found on upper endoscopy. These polyps are typically asymptomatic, smaller than 1 cm, and located in the gastric fundus and/or gastric body; they can be solitary but are more often multiple. They can be sporadic or can result from long-term proton pump inhibitor (PPI) use (>12 months). Dysplasia is exceedingly rare; sporadic fundic gland polyps progressing to cancer have not been reported. In fact, dysplastic changes typically affect only polyps larger than 1 cm. Some polyp characteristics can raise concern: symptomatic polyps, polyps larger than 1 cm, polyps in the gastric antrum, or polyps with an abnormal appearance. In these patients, the polyp should be completely resected rather than being biopsied. Polyps later found to contain dysplasia on biopsy are also of concern, and repeat upper endoscopy should be promptly performed to completely remove these polyps. If fundic gland polyps are histologically confirmed and no dysplasia or concern for syndromic polyps is present (as in this patient), no further endoscopic follow-up is needed.
Universal recommendations for surveillance when dysplasia is found are lacking, although expert opinion suggests that initial surveillance upper endoscopy be pursued at 1 year (Option A), with the interval of subsequent upper endoscopies to be determined by findings, given the polyps' slow rate of growth, such as over 3 to 5 years (Option B). Repeat upper endoscopy should be considered at an even shorter interval, such as 6 months for polyps with high-grade dysplasia. Fundic gland polyps can be syndromic in association with the familial adenomatous polyposis syndrome. In this setting, dysplasia is common (present in 25% to more than 50% of polyps). The finding of a carpet of fundic gland polyps (>50 polyps) in a young patient, especially one not taking a PPI, and/or the presence of dysplasia should raise suspicion for familial adenomatous polyposis and prompt further evaluation with a colonoscopy. In the setting of PPI-induced sporadic fundic gland polyps with no strong indication for PPI use, discontinuation of PPI should be discussed, although the data are mixed on whether PPI-associated sporadic fundic gland polyps regress after PPI discontinuation.
Repeat endoscopy in 10 years (Option C) is not recommended for any gastric polyp setting.
Key Point
- Fundic gland polyps are the most common benign epithelial gastric polyp and require no endoscopic follow-up.