Hyperplastic Duodenal Polyp in Portal Hypertensive Gastrointestinal Disease

Experienced teaching points

Clinical Pearls

Inflammatory polyps can occur in the setting of portal hypertension and cirrhosis, an unusual gastrointestinal presentation that extends the recognized spectrum beyond varices and gastropathy.
Chronic anemia and positive stool occult blood tests in cirrhotic patients warrant thorough endoscopic evaluation for unusual lesions beyond typical varices or portal hypertensive gastropathy.
A Kudo classification IIIL and IV pit pattern on a duodenal polyp in a cirrhotic patient should prompt consideration of an inflammatory etiology with foveolar metaplasia, not just neoplasia.
Endoscopic resection using a hot snare with saline injection and clip closure is an effective treatment for pedunculated inflammatory polyps in the duodenum.

Final Diagnosis

Duodenal inflammatory polyp with surface erosion and gastric foveolar surface metaplasia, resected via hot snare polypectomy.

Patient Demographics

A 71-year-old female patient with a history of metabolic-associated hepatic steatosis and cirrhosis.

Clinical History

The patient presented for Esophagogastroduodenoscopy due to chronic anemia and guaiac-positive stools.

Endoscopic Findings

Upon upper endoscopy, the esophagus demonstrated normal mucosa. Diffuse portal hypertensive gastropathy was noted. Small gastric fundic gland polyps were observed. In the duodenum, a large, pedunculated polypoid lesion was identified. The lesion exhibited areas of erosion on its surface. The mucosal surface pattern of the polyp showed an irregular pit pattern consistent with Kudo classification IIIL and IV. Final histological analysis of the resected lesion revealed an inflammatory-type polyp with multifocal surface erosion and ulceration, associated with active inflammation and scattered foci of gastric foveolar surface metaplasia.

Endoscopic Technique

The base of the duodenal lesion was injected with 1.5 mL of normal saline. The lesion was then resected using a hot snare technique. The resulting defect was closed with an endoscopic clip.

Discussion

This case illustrates an unusual gastrointestinal presentation of cirrhosis with portal hypertension. Patients with cirrhosis and portal hypertension may present with various upper gastrointestinal abnormalities, including esophageal varices, portal hypertensive gastropathy, portal hypertensive enteropathy, colonopathy, and rectal varices (1-3). We have also described the presence of gastric antral vascular ectasia (GAVE)-like lesions in the cardia in patients with portal hypertension and cirrhosis (4). While GAVE, also known as watermelon stomach, is a recognized manifestation of portal hypertension, other lesions are less known and less frequently recognized. This case is notable because it demonstrates that inflammatory polyps can present in patients with cirrhosis and portal hypertension.

Key Learning Points

Inflammatory polyps can occur in the setting of portal hypertension and cirrhosis.
Chronic anemia and positive stool occult blood tests in cirrhotic patients warrant thorough endoscopic evaluation for unusual lesions beyond typical varices or gastropathy.
Endoscopic resection using a hot snare with saline injection and clip closure is an effective treatment for such lesions.
Histopathological analysis is crucial for definitive diagnosis of unusual polypoid lesions in portal hypertensive patients.

References

Hashiba Y, Okai K, Tokuhira R, et al. Histological characteristics of gastric hyperplastic polyps in patients with portal hypertension. Dig Endosc. 2011;23(4):307-313.
Koulaouzidis A, Bhatnagar S, Rondonotti E, et al. Duodenal pathology in patients with portal hypertension: A systematic review. World J Gastrointest Endosc. 2013;5(11):532-539.
Tripathi D, Makharia GK. Portal hypertensive gastropathy and enteropathy: Current concepts. J Clin Exp Hepatol. 2014;4(2):167-176.
Monkemuller K, Dwivedi A. CAVE - Cardia Antral Vascular Ectasias - A New Entity? The Practicing Endoscopist. https://thepracticingendoscopist/p/cave

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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