Gastroenterology clinical image challenge: A 62-year-old man with a history of coronary artery disease presented to our institution for evaluation of profound gastric polyposis after routine upper endoscopy for evaluation of progressive iron deficiency anemia. A family history was obtained and was remarkable for a daughter who died at age 32 from stage IV gastric adenocarcinoma in the setting of similar gastric polyposis; there was no known family history of colon cancer or other associated Lynch syndrome cancers. The presence of gastric polyposis preceded initiation of proton pump inhibitor therapy.
Given the history of unexplained iron deficiency, upper endoscopy and colonoscopy were performed. Upper endoscopy revealed diffuse profound fundic gland-like polyps heaped up throughout the gastric fundus, cardia, and body with notable sparing of the antrum and duodenum. Colonoscopy was significant only for two small (<5 mm) nondysplastic tubular adenomas. A computed tomography scan with pancreas protocol was performed and did not reveal any lesions suspicious for extraintestinal gastrinoma. Consultation with a genetic counselor was pursued and confirmed the presence of APC gene mutation c.-191T>C. The patient ultimately underwent total gastrectomy revealing a large bulky stomach that was difficult to mobilize due to size with features consistent with endoscopic evaluation (figure). Histologic evaluation revealed numerous fundic gland polyps, several of which contained focal adenomatous transformation with low-grade dysplasia.
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