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Inflammatory gastric polyps (eosinophilic granulomas of the stomach)
Inflammatory Gastric Polyps (Eosinophilic Granulomas of the Stomach) EVERETTCARLSON,M.D. ANDJOHN GUY WARD, M.D., San Francisco, Calijornia
From the Surgical Service, St. Francis Francisco, Calijornia.
Hospital,
ports have appeared, indicating that this Iesion is probabIy not as rare as was formerIy supposed [13]. EosinophiIic infiItration of the stomach may occur in a diffuse form or as a IocaIized poIypoid Iesion [1,9,12]. It is with the latter that we are concerned in this discussion. In the former, the duodenum, jejunum or iIeum may have simiIar associated Iesions [4,1o,r4]. PoIayes and Krieger reported a case in which the jejunum aIone was invoIved and resected [II]. In the diffuse type, an increase of eosinophiIs in the periphera1 circuIation in nearly a11the patients reported on has been observed, even up to 60 per cent in one patient. However, in the poIypoid Iesions such eosinophiIia has not been noted. The eosinophiIia in the diffuse type has Ied to a consideration of aIIergy as an etioIogic factor. Kaijser reported two cases which he attributed to neoarsphenamine. In a third, ingestion of onions repeatedIy was folIowed by a severe recurrence of symptoms [8]. In the two cases reported by Polayes and Krieger, the etioIogy appeared to be oidium and trichophyton, respectiveIy [II]. In Spencer, Comfort and Dahlin’s case, emetine was administered with reIief of symptoms [r4]. Asthma and urticaria were aIso present in this patient. The use of ACTH with striking reIief of symptoms in the patients reported on by Ferrier and Orr aIso supports the suspicion of an aIIergic factor [q,ro]. LocaIized trauma has been suggested as a cause in singIe poIypoid Iesions. The Iesions have occurred with about equa1 frequency in maIes and femaIes; most have been persons of middIe or advanced age. The youngest patient was thirty-one years of age [13].
Sun
recent years an increasing number of cases of inflammatory fibroid poIyps is being recognized [13,15]. These are not innocent lesions, and it is important for surgeons to be famiIiar with them. In the past the condition in nearly alI the operated patients was mistaken for carcinoma, and hence extensive resections were performed [15]. FortunateIy, most of the lesions were Iocated in the dista1 haIf of the stomach, where such resections resuIted in good functiona resuIts. A review of the Iiterature to date reveaIs no cases of maIignancy in these Iesions. Two cases are reported herein. In the first the Iesion was located on the posterior waI1 of the fundus, and in the second in the midportion of the stomach on the Iesser curvature. Both were Iarge Iesions and were diagnosed preoperativeIy as maIignant; both were benign. BIeeding, in the first patient in gradua1, unrecognized amounts, and in the second, massive hemorrhage, necessitated surgery. Because of the presence of eosinophilic infltration, often to a striking degree, earIier investigators designated these Iesions as eosinophiIic granuIomas of the stomach. The first cases were described by Kaijser in 1937 [8]. His findings were Iater discussed by Vanek, and six additiona cases were reported by him in 1949 [15]. HeIwig and Ranier, after studying nine further cases in 1952, proposed the term inffammatory fibroid polyp [7]. In 1953 BuIIock and Moran reported five more cases, in three of which the Iesions were resected [2]. They urged the adoption of this term. Other terms by which these Iesions have been designated in the past are gastric submucosa1 granulomas with eosinophiIic infiItration, granuIomatous poIyps, submucous granulomas, fibromas and hemangiopericytomas. Since then, further case re-
I
N
American
Journal
of Surgery, Vdume
9% March.
1960
PATHOLOGY The essentia1 distinguishing features of these Iesions, according to Vanek [15], are: (I) a sub352
Inflammatory
Gastric
PoIyps
mucosal stroma made up of fibroblasts and coIIagen fibers, with or without edema, (2) an infiltration of the stroma with eosinophiIic leukocytes and lymphocytes, the latter occasionaIIy in rudimentary lymph foIIicIes, (3) the presence in the stroma of arterioles, blood and Iymph capiIIaries, and (4) a mucous membrane covering which, in pIaces, may be uIcerated or replaced by granuIation tissue. These Iesions are predominantIy Iocalized in the submucosa, with or without invorvement of the underlying muscuIaris. Both sessiIe and peduncuIated Iesions have been reported. CLINICAL
FINDINGS
In most patients, epigastric pain of variabIe duration and degree has been present. However, a few patients, incIuding our Case I, had no pain whatever. Most patients had some dyspepsia. Anorexia, beIching, sour regurgitation and nausea were much more common than vomiting, which occurred in some. Tarry stooIs were noted occasionaIIy. Occult bIood in the stooIs was frequent. Symptoms due to anemia, 0ccasionaIIy severe, were not uncommon. Weight Ioss occurred in a number of patients. PhysicaI findings in most patients were not impressive. In onIy a very few couId a tumor be palpated. Some vague guarding and miId tenderness of the upper quadrant of the abdomen were occasionaIIy eIicited. PaIIor was present in some. Evidence of weight Ioss was not a conspicuous feature in most. Free hydrochIoric acid, without histamine, was absent in thirteen of fourteen cases reported by Smirnov. In his remaining seven patients, given histamine, free acid was found in two. Anemia of varying degree was present in nineteen of his twenty-one patients [I?]. CASE
FIG. I. Case I. An elongated, slightly IobuIated, polypoid mass, just below the fundus. Benign inflammatory poIyp. day. She had undergone appendectomy many years previousIy, a large benign cervica1 poIyp had been removed ten years prior to admission, and some hemorrhoids injected two years earIier. She had had two chiIdren. Otherwise, except for a stormy menopause and miId arthritic symptoms, she had been in good health. Her famiIy history was non-contributory. Examination reveaIed a sIightIy obese, very paIe patient with marked edema of both Iegs and feet. The Iungs were clear and the heart appeared normal. Blood pressure was 100/60 mm. Hg. P&e rate was go and regular. EIectrocardiographic data were reported as foIIows: rate, 91; P-R interval, o. I 6; heart position, semi-horizontal, countercIockwise rotation. The P wave was low in Ieads I and aVL. The QRS wave was sIurred in lead III. The ST segment was depressed in Iead II. AbnormaI record showed intraventricuIar conduction defect. In the right part of the mid-abdomen a questionabIe mass was feIt, suggesting carcinoma of the ascending colon. The red bIood count on admission was 2,600,000 per cu. mm. with 6.2 gm. of hemogIobin (40 per cent). The packed ceI1 voIume was 19 cc. per IOO cc. There was a moderate microcytosis, slight hypochromia and poikiIocytosis. A gastric analysis, with histamine, showed no free acid in the fasting specimen, and a tota hydrochloric acid of 12 degrees. The subsequent specimens at fifteen-minute intervals rose to 62, 84, go and 102 degrees free, and 76, I I 8, 102 and
REPORTS
This fifty-nine year oId white woman, a saIes executive, entered the St. Francis HospitaI on August 19, 1958, compIaining of weakness, dyspnea on exertion, paIpitation, excessive perspiration, headaches, cramp-like pains in her calves and edema of the ankIes of three to four months’ duration. Her symptoms were becoming progressively severe but she had been able to continue at work with diffIcuIty. Her appetite was good but she regurgitated sIight amounts of food occasionaIIy without nausea. Her weight had remained stationary. BoweI movements and stooIs had been normaI, except that once, two weeks previously, she had noted some bIack, tar-Iike stooIs for one CASE I.
353
CarIson and Ward
FIG. 2. Case I. Gross specimen.
LobuIated broad pedicIe (indicated by arrows).
FIG. 3.
surface and
UrinaIysis was negative for I 12 degrees totaI. abnormahties. A barium enema on August 20, rg$3, faiIed to confirm the impression of a Iesion in the ascending coIon. The resuIts of an upper gastrointestina1 roentgenogram taken on August 21 were reported as foIIows: In the esophagus, nothing abnorma1 was seen. In the stomach, just beIow the fundus, was an elongated, sIightIy IobuIated, poIypoid mass measuring 3 by 6 cm. (Fig. I.) This region of the stomach appeared to be flexible. The remainder of the stomach and duodenum appeared essentiaIIy norma except for some ptosis. The stomach emptied in four hours. On August 27, 1958, after preparing the patient with five blood transfusions and vitamins, Iaparotomy was performed. The preoperative diagnosis was a maIignant poIyp of the stomach. An incision was made into the upper left rectus muscIe. A movable poIypoid mass couId be palpated in the
FIG. 4. Case II. Benign inflammatory CARLSON, E. and WARD, J. G. [3].)
poIyp.
Case 1. Cross section.
posterior wall at the junction of the upper and middIe thirds of the stomach. The gastrocolic ligament was severed, mobiIizing the greater curvature. The posterior serosa appeared normaI, the tumor apparently being confined to the mucosa and submucosa. A Iongitudinal incision was made through the anterior wall of the upper haIf of the stomach; the tumor was grasped and readiIy delivered. With traction on the tumor, Kocher cIamps were applied to the waI1 of the stomach at about 2 cm. from its base, and the Iesion was resected. A row of interrupted chromic No, o mattress sutures was appIied proxima1 to the clamps, and the cIamps were removed. A second row of continuous chromic No. o sutures was used to reinforce the mattress sutures. The waI1 of the stomach was cIosed with one continuous Iine of No. o chromic sutures, reinforced by interrupted No. 3-o black silk. The abdomen was cIosed without drainage. On the first postoperative day severe pain deveIoped in the calf of the Ieft leg, and marked sweIIing of this leg and thigh occurred. A Iumbar sympathetic bIock with Novocaine” was given. Heparin was administered intravenousIy, together with papaverin. The thrombophIebitis gradually improved, and the patient became ambuIatory, wearing an eIastic stocking, on the eighth day. Except for this her convaIescence was rapid and uneventful. Subsequent bIood counts and gastric analyses showed no recurrence of the anemia, and a normal acidity. The pathoIogic report was as foIIows: The specimen consisted of an irreguIar polypoid mass of gastric mucosa with a pedicIe which measured 4.0 cm. in diameter, 8.0 cm. across the top and 3.0 cm. in width, and was eIevated 4.0 cm. above the surface. There was marked pebbIing of the mucosa, and there were severa mushroom-like projections, one at either end, which measured 2.0 cm. in length by 2.0 cm. in diameter. Both of these showed superficia1 erosion and partia1 heaIing
(FROM:
354
Inflammatory
Gastric PoIyps
FIG. 5. Case II. Gross specimen. Benign inflammatory polyp of posterior waII of the mid-stomach. (FROM: CARLSON, E. and WARD, J. G. [j].)
FIG. 6. Case II. Cross section showing soIid tumor arising from submucosa, with absence of mucosa over surface. (FROM: CARLSON, E. and WARD, J. G. 131.)
of the mucosa. (Fig. 2.) This may we11 have been the source of hemorrhage. The tissue was soft and spongy. A frozen section taken at the base of one of the lateral polyps was reported as benign. The mucosa was pink-tan to red-gray. On section the stroma was made up of Ioose areoIar, pink-white connective tissue and lobules of fat. Microscopically, sections showed several polypoid masses of gastric mucosa with severa areas of superficial erosion and with a necrotic peIIicle on the surface. The mucosa varied in thickness, but had a norma distribution of ceIIs. The underIying tissue was composed of interlacing bands of dense fibrous connective tissue in which a fairly dense inffammatory infiItrate was present with Iymphocytes, pIasma ceIIs and many eosinophils. There were numerous dilated bIood vessels, and severa large vesseIs with thickened waIIs were present. (Fig. 3.) The deeper glands showed no abnormaIities and there was no evidence of malignancy or penetration of the underlying tissue. In the deeper portion of the stroma one saw norma Iobular fat. A few markedly diIated glands were present in the deep portion of the stroma Iined by taI1 coIumnar mucus-secreting gIands. These were apparentIy deep crypts which connected with the surface. No evidence of maIignancy was seen. The microscopic diagnosis was inflammatory fibroid poIyp.
tent. She had considerable IIatuIence and belching and was unabIe to eat, but had not vomited. Tarry stools were noted two days after the onset of pain. She was very obese, and had had no recent weight loss. Eight years previousIy an upper gastrointestina1 roentgenogram, taken because of mild discomfort, had been reported as “uIcers.” These
CASE II.* This sixty-five year oId Jewish widow was admitted to the St. Francis HospitaI on October 23, 1957, by Dr. L. Custer for severe anemia, presumably due to upper gastrointestina1 bIeeding. Six days previousIy severe pain had deveIoped in her back which radiated around to the right upper quadrant. It was constant and persis* PreviousIy reported in and cited by permission Surgery, Gynecology and Obstetrics [3].
of
FIG. 7. Case II. Microscopic sections. Tumor composed of stellate- to spindIe-shaped ceIIs (fibrobIasts) admixed with capiIIaries. Eosinophilic infiltration throughout. A, absence of mucosa over surface. B, mucosa of adjacent stomach waI1.
355
Car&on
and
Ward
have a tendency to prolapse and obstruct which is undoubtedly a cause of pain. Lobulation of the lesions, as in Case I, has not been noted often. Since inflammatory poIyps do not have the malignant potentia1 of adenomatous poIyps, treatment obviously need not be as radica1 as for the Iatter. However, since inflammatory poIyps are much rarer than adenomatous poIyps, there being onIy two in our coIIected series of seventy-live cases, and since their gross appearance may cIoseIy resembIe adenomatous poIyps, it appears to us that the only safe course to follow when encountering a singIe polypoid lesion is to excise it together with the fuI1 thickness of the adjacent stomach wall. This enables the pathologist to adequately identify the lesion and ascertain if invasion at its base has occurred. One shouId bear in mind, when deaIing with Iesions in the fundus particuIarIy, that they might be of this character, and avoid disabIing high resections if unnecessary. SimpIe poIypectomy, as we performed in Case I, may not aIways be adequate to provide the pathoIogist with a satisfactory specimen.
fifms were not avaiIabie. Her family history and past history were otherwise non-contributory. Examination revealed marked pallor, obesity and tenderness to deep paIpation in the epigastrium. The red blood count was 2,560,ooo per cu. mm. with 7 gm. (45 per cent) hemoglobin. Gastric anaIysis was not performed. An upper gastrointestinal roentgenogram showed a smooth hemispherical defect on the mid-portion of the lesser curvature, with a 3 cm. centra1 uIceration. (Fig. 4.) The diagnosis made from the x-ray fiIm was carcinoma of the stomach. The possibility of a Ieiomyoma or Ieiomyosarcoma was seriously considered. At operation on October 28, 1957, a smooth, sessile, polypoid tumor measuring 4.5 cm. in its maximum diameter, 3 cm. high and 3.5 cm. across its base was found. (Fig. 5.) SubtotaI gastrectomy was performed. The pathoIogic report was a benign inflammatory fibrinoid polyp (submucosa1 eosinophilic granuIoma of the stomach). (Figs. 6 and 7.) Recovery was uneventful, and the patient has remained well and asymptomatic. COMMENTS
AU inflammatory fibroid poIyps reported to date have been benign. This is in contrast to adenomatous poIyps, which, in a recently collected series, we found 16.6 per cent of the single ones to be mahgnant [3]. In adenomatous poIyps, Hay found over 50 per cent of those over 2 cm. in diameter to be maIignant [5,6]. Both of our patients had large lesions, Ieading to the preoperative diagnosis of maIignancy. Adenomatous polyps are frequentIy muItipIe. In our series of seventy-four coIIected cases, about one-third were muItipIe. OnIy one case of muItipIe inflammatory fibroid poIyps has been reported in the literature [13]. It is common to find carcinoma of the stomach associated with adenomatous poIyps but as yet, no case has been reported with an inffammatory poIyp. The mucosa1 surfaces of inflammatory poIyps frequently uIcerate, Ieading to gradua1 or unrecognized Ioss of bIood as in our Case I, or to massive hemorrhage as in Case II. Pain in inflammatory poIyps was a frequent symptom in those cases Iocated in the antrum or prepyIoric region. In our Case I in which the Iesion was in the fundus, pain was entireIy absent, the principa1 symptoms being due to a severe anemia. WhiIe our two reported Iesions had broad, sessiIe bases, a number of peduncuIated infIammatory polyps have been reported. When Iocated in the prepyIoric region, they
SUMMARY
AND
CONCLUSIONS
Inflammatory fibroid poIyps (eosinophilic granulomas of the stomach) and eosinophilic inMtration are described herein and their distinguishing pathologica characteristics reviewed. EtioIogy, cIinica1 aspects, treatment and prognosis are discussed. Two cases with serious compIications requiring surgery are reported. Since these Iesions are benign in character, surgical treatment need not be as extensive as in adenomatous poIyps, and IocaI excision with the fuI1 thickness of the adjacent stomach wall appears at present to be adequate if the Iesion can be identified as an inflammatory poIyp, with a reasonabIe degree of assurance. REFERENCES
BARRIE, H. J. and ANDERSON,J. C. Hypertrophy of the pylorus in au adult with massive eosinophil infiltration and giant cell reaction. Lancet, 2: 1007-1009, 1948. z. BULLOCK, W. K. and MORAN, E. T. Inflammatory fibroid polyps of the stomach. Cancer, 6: 488-493, 1953. 3. CARLSON, E. and WARD, J. G. Surgical considerations in gastric polyps, polyposis and giant hypertrophic gastritis in 74 cases. Surg., Gynec. ti Obst., 107: 727-738, 1958. I.
356
InA ammatory Gastric PoIyps 4. FERRIER,T. and DAVIS, B. Eosinophil infiItration of the stomach and smaII intestine. M. J. Australia, I : 789791, 1957. 5. HAY, L. H. Gastric poIyps, a cIinica1 study. Minnesota Med., 34: 362-364, 1951. 6. HAY, L. H. SurgicaI management of gastric poIyps and adenomas. Surgery, 36: 114-119, 1956. 7. HELWIG, E. G. and RANIER, A. Inflammatory fibroid polyps of the stomach. Surg., Gynec. @ Obst., 96: 355-367, 1953. 8. KAIJSER, R. iiber Hgmangiome des Tractus Gastrointestinahs. Arch. f. klin. Cbir., 187: 351, 1936. Cited by Vanek, J. [IS]. g. MOLONEY, G. E. PyIoric hypertrophy with eosinophi1 infiItration. Lancet, I : 412, 1949. IO. ORR, I. M., MILLER, A. A. and RUSSELL, J. Y. W. Eosinophilic infiItration of the stomach and bowel. Post-Grad. M. J., 30: 485-493, 1954.
II.
POLAYES, S. H. and KRIECER, J. L. Eosinophilic
granuIoma
of the jejunum.
J. A. M. A.,
143:
549-551, 1950. 12. RUSIC, J. P., DORSEY, J. M., HUBER, J. L. and ARMSTRONG,S. H., JR. Gastric lesion of Loeffler’s syndrome. Report of a case with inflammatory Iesion simuIating carcinoma. J. A. M. A., 149: 534-537. 1952. 13. SMIRNOV, N. M. GranuIomatous polypi of the stomach. Problems of Oncology, 3: 306311, 1957. 14. SPENCER, J. R., COMFORT, M. W. and DAHLIN, D. C. EosinophiIic infdtration of the stomach and bowe1, associated with pyIoric obstruction and recurrent eosinophiIia. Gastroaterology, 15: 5055’3, ‘950. 15. VANEK, J. Gastric submucosa1 granuIoma with eosinophilic infiltration. Am. J. Path., 25: 397411, 1949.
357
From the Surgical Service, St. Francis Francisco, Calijornia.
Hospital,
ports have appeared, indicating that this Iesion is probabIy not as rare as was formerIy supposed [13]. EosinophiIic infiItration of the stomach may occur in a diffuse form or as a IocaIized poIypoid Iesion [1,9,12]. It is with the latter that we are concerned in this discussion. In the former, the duodenum, jejunum or iIeum may have simiIar associated Iesions [4,1o,r4]. PoIayes and Krieger reported a case in which the jejunum aIone was invoIved and resected [II]. In the diffuse type, an increase of eosinophiIs in the periphera1 circuIation in nearly a11the patients reported on has been observed, even up to 60 per cent in one patient. However, in the poIypoid Iesions such eosinophiIia has not been noted. The eosinophiIia in the diffuse type has Ied to a consideration of aIIergy as an etioIogic factor. Kaijser reported two cases which he attributed to neoarsphenamine. In a third, ingestion of onions repeatedIy was folIowed by a severe recurrence of symptoms [8]. In the two cases reported by Polayes and Krieger, the etioIogy appeared to be oidium and trichophyton, respectiveIy [II]. In Spencer, Comfort and Dahlin’s case, emetine was administered with reIief of symptoms [r4]. Asthma and urticaria were aIso present in this patient. The use of ACTH with striking reIief of symptoms in the patients reported on by Ferrier and Orr aIso supports the suspicion of an aIIergic factor [q,ro]. LocaIized trauma has been suggested as a cause in singIe poIypoid Iesions. The Iesions have occurred with about equa1 frequency in maIes and femaIes; most have been persons of middIe or advanced age. The youngest patient was thirty-one years of age [13].
Sun
recent years an increasing number of cases of inflammatory fibroid poIyps is being recognized [13,15]. These are not innocent lesions, and it is important for surgeons to be famiIiar with them. In the past the condition in nearly alI the operated patients was mistaken for carcinoma, and hence extensive resections were performed [15]. FortunateIy, most of the lesions were Iocated in the dista1 haIf of the stomach, where such resections resuIted in good functiona resuIts. A review of the Iiterature to date reveaIs no cases of maIignancy in these Iesions. Two cases are reported herein. In the first the Iesion was located on the posterior waI1 of the fundus, and in the second in the midportion of the stomach on the Iesser curvature. Both were Iarge Iesions and were diagnosed preoperativeIy as maIignant; both were benign. BIeeding, in the first patient in gradua1, unrecognized amounts, and in the second, massive hemorrhage, necessitated surgery. Because of the presence of eosinophilic infltration, often to a striking degree, earIier investigators designated these Iesions as eosinophiIic granuIomas of the stomach. The first cases were described by Kaijser in 1937 [8]. His findings were Iater discussed by Vanek, and six additiona cases were reported by him in 1949 [15]. HeIwig and Ranier, after studying nine further cases in 1952, proposed the term inffammatory fibroid polyp [7]. In 1953 BuIIock and Moran reported five more cases, in three of which the Iesions were resected [2]. They urged the adoption of this term. Other terms by which these Iesions have been designated in the past are gastric submucosa1 granulomas with eosinophiIic infiItration, granuIomatous poIyps, submucous granulomas, fibromas and hemangiopericytomas. Since then, further case re-
I
N
American
Journal
of Surgery, Vdume
9% March.
1960
PATHOLOGY The essentia1 distinguishing features of these Iesions, according to Vanek [15], are: (I) a sub352
Inflammatory
Gastric
PoIyps
mucosal stroma made up of fibroblasts and coIIagen fibers, with or without edema, (2) an infiltration of the stroma with eosinophiIic leukocytes and lymphocytes, the latter occasionaIIy in rudimentary lymph foIIicIes, (3) the presence in the stroma of arterioles, blood and Iymph capiIIaries, and (4) a mucous membrane covering which, in pIaces, may be uIcerated or replaced by granuIation tissue. These Iesions are predominantIy Iocalized in the submucosa, with or without invorvement of the underlying muscuIaris. Both sessiIe and peduncuIated Iesions have been reported. CLINICAL
FINDINGS
In most patients, epigastric pain of variabIe duration and degree has been present. However, a few patients, incIuding our Case I, had no pain whatever. Most patients had some dyspepsia. Anorexia, beIching, sour regurgitation and nausea were much more common than vomiting, which occurred in some. Tarry stooIs were noted occasionaIIy. Occult bIood in the stooIs was frequent. Symptoms due to anemia, 0ccasionaIIy severe, were not uncommon. Weight Ioss occurred in a number of patients. PhysicaI findings in most patients were not impressive. In onIy a very few couId a tumor be palpated. Some vague guarding and miId tenderness of the upper quadrant of the abdomen were occasionaIIy eIicited. PaIIor was present in some. Evidence of weight Ioss was not a conspicuous feature in most. Free hydrochIoric acid, without histamine, was absent in thirteen of fourteen cases reported by Smirnov. In his remaining seven patients, given histamine, free acid was found in two. Anemia of varying degree was present in nineteen of his twenty-one patients [I?]. CASE
FIG. I. Case I. An elongated, slightly IobuIated, polypoid mass, just below the fundus. Benign inflammatory poIyp. day. She had undergone appendectomy many years previousIy, a large benign cervica1 poIyp had been removed ten years prior to admission, and some hemorrhoids injected two years earIier. She had had two chiIdren. Otherwise, except for a stormy menopause and miId arthritic symptoms, she had been in good health. Her famiIy history was non-contributory. Examination reveaIed a sIightIy obese, very paIe patient with marked edema of both Iegs and feet. The Iungs were clear and the heart appeared normal. Blood pressure was 100/60 mm. Hg. P&e rate was go and regular. EIectrocardiographic data were reported as foIIows: rate, 91; P-R interval, o. I 6; heart position, semi-horizontal, countercIockwise rotation. The P wave was low in Ieads I and aVL. The QRS wave was sIurred in lead III. The ST segment was depressed in Iead II. AbnormaI record showed intraventricuIar conduction defect. In the right part of the mid-abdomen a questionabIe mass was feIt, suggesting carcinoma of the ascending colon. The red bIood count on admission was 2,600,000 per cu. mm. with 6.2 gm. of hemogIobin (40 per cent). The packed ceI1 voIume was 19 cc. per IOO cc. There was a moderate microcytosis, slight hypochromia and poikiIocytosis. A gastric analysis, with histamine, showed no free acid in the fasting specimen, and a tota hydrochloric acid of 12 degrees. The subsequent specimens at fifteen-minute intervals rose to 62, 84, go and 102 degrees free, and 76, I I 8, 102 and
REPORTS
This fifty-nine year oId white woman, a saIes executive, entered the St. Francis HospitaI on August 19, 1958, compIaining of weakness, dyspnea on exertion, paIpitation, excessive perspiration, headaches, cramp-like pains in her calves and edema of the ankIes of three to four months’ duration. Her symptoms were becoming progressively severe but she had been able to continue at work with diffIcuIty. Her appetite was good but she regurgitated sIight amounts of food occasionaIIy without nausea. Her weight had remained stationary. BoweI movements and stooIs had been normaI, except that once, two weeks previously, she had noted some bIack, tar-Iike stooIs for one CASE I.
353
CarIson and Ward
FIG. 2. Case I. Gross specimen.
LobuIated broad pedicIe (indicated by arrows).
FIG. 3.
surface and
UrinaIysis was negative for I 12 degrees totaI. abnormahties. A barium enema on August 20, rg$3, faiIed to confirm the impression of a Iesion in the ascending coIon. The resuIts of an upper gastrointestina1 roentgenogram taken on August 21 were reported as foIIows: In the esophagus, nothing abnorma1 was seen. In the stomach, just beIow the fundus, was an elongated, sIightIy IobuIated, poIypoid mass measuring 3 by 6 cm. (Fig. I.) This region of the stomach appeared to be flexible. The remainder of the stomach and duodenum appeared essentiaIIy norma except for some ptosis. The stomach emptied in four hours. On August 27, 1958, after preparing the patient with five blood transfusions and vitamins, Iaparotomy was performed. The preoperative diagnosis was a maIignant poIyp of the stomach. An incision was made into the upper left rectus muscIe. A movable poIypoid mass couId be palpated in the
FIG. 4. Case II. Benign inflammatory CARLSON, E. and WARD, J. G. [3].)
poIyp.
Case 1. Cross section.
posterior wall at the junction of the upper and middIe thirds of the stomach. The gastrocolic ligament was severed, mobiIizing the greater curvature. The posterior serosa appeared normaI, the tumor apparently being confined to the mucosa and submucosa. A Iongitudinal incision was made through the anterior wall of the upper haIf of the stomach; the tumor was grasped and readiIy delivered. With traction on the tumor, Kocher cIamps were applied to the waI1 of the stomach at about 2 cm. from its base, and the Iesion was resected. A row of interrupted chromic No, o mattress sutures was appIied proxima1 to the clamps, and the cIamps were removed. A second row of continuous chromic No. o sutures was used to reinforce the mattress sutures. The waI1 of the stomach was cIosed with one continuous Iine of No. o chromic sutures, reinforced by interrupted No. 3-o black silk. The abdomen was cIosed without drainage. On the first postoperative day severe pain deveIoped in the calf of the Ieft leg, and marked sweIIing of this leg and thigh occurred. A Iumbar sympathetic bIock with Novocaine” was given. Heparin was administered intravenousIy, together with papaverin. The thrombophIebitis gradually improved, and the patient became ambuIatory, wearing an eIastic stocking, on the eighth day. Except for this her convaIescence was rapid and uneventful. Subsequent bIood counts and gastric analyses showed no recurrence of the anemia, and a normal acidity. The pathoIogic report was as foIIows: The specimen consisted of an irreguIar polypoid mass of gastric mucosa with a pedicIe which measured 4.0 cm. in diameter, 8.0 cm. across the top and 3.0 cm. in width, and was eIevated 4.0 cm. above the surface. There was marked pebbIing of the mucosa, and there were severa mushroom-like projections, one at either end, which measured 2.0 cm. in length by 2.0 cm. in diameter. Both of these showed superficia1 erosion and partia1 heaIing
(FROM:
354
Inflammatory
Gastric PoIyps
FIG. 5. Case II. Gross specimen. Benign inflammatory polyp of posterior waII of the mid-stomach. (FROM: CARLSON, E. and WARD, J. G. [j].)
FIG. 6. Case II. Cross section showing soIid tumor arising from submucosa, with absence of mucosa over surface. (FROM: CARLSON, E. and WARD, J. G. 131.)
of the mucosa. (Fig. 2.) This may we11 have been the source of hemorrhage. The tissue was soft and spongy. A frozen section taken at the base of one of the lateral polyps was reported as benign. The mucosa was pink-tan to red-gray. On section the stroma was made up of Ioose areoIar, pink-white connective tissue and lobules of fat. Microscopically, sections showed several polypoid masses of gastric mucosa with severa areas of superficial erosion and with a necrotic peIIicle on the surface. The mucosa varied in thickness, but had a norma distribution of ceIIs. The underIying tissue was composed of interlacing bands of dense fibrous connective tissue in which a fairly dense inffammatory infiItrate was present with Iymphocytes, pIasma ceIIs and many eosinophils. There were numerous dilated bIood vessels, and severa large vesseIs with thickened waIIs were present. (Fig. 3.) The deeper glands showed no abnormaIities and there was no evidence of malignancy or penetration of the underlying tissue. In the deeper portion of the stroma one saw norma Iobular fat. A few markedly diIated glands were present in the deep portion of the stroma Iined by taI1 coIumnar mucus-secreting gIands. These were apparentIy deep crypts which connected with the surface. No evidence of maIignancy was seen. The microscopic diagnosis was inflammatory fibroid poIyp.
tent. She had considerable IIatuIence and belching and was unabIe to eat, but had not vomited. Tarry stools were noted two days after the onset of pain. She was very obese, and had had no recent weight loss. Eight years previousIy an upper gastrointestina1 roentgenogram, taken because of mild discomfort, had been reported as “uIcers.” These
CASE II.* This sixty-five year oId Jewish widow was admitted to the St. Francis HospitaI on October 23, 1957, by Dr. L. Custer for severe anemia, presumably due to upper gastrointestina1 bIeeding. Six days previousIy severe pain had deveIoped in her back which radiated around to the right upper quadrant. It was constant and persis* PreviousIy reported in and cited by permission Surgery, Gynecology and Obstetrics [3].
of
FIG. 7. Case II. Microscopic sections. Tumor composed of stellate- to spindIe-shaped ceIIs (fibrobIasts) admixed with capiIIaries. Eosinophilic infiltration throughout. A, absence of mucosa over surface. B, mucosa of adjacent stomach waI1.
355
Car&on
and
Ward
have a tendency to prolapse and obstruct which is undoubtedly a cause of pain. Lobulation of the lesions, as in Case I, has not been noted often. Since inflammatory poIyps do not have the malignant potentia1 of adenomatous poIyps, treatment obviously need not be as radica1 as for the Iatter. However, since inflammatory poIyps are much rarer than adenomatous poIyps, there being onIy two in our coIIected series of seventy-live cases, and since their gross appearance may cIoseIy resembIe adenomatous poIyps, it appears to us that the only safe course to follow when encountering a singIe polypoid lesion is to excise it together with the fuI1 thickness of the adjacent stomach wall. This enables the pathologist to adequately identify the lesion and ascertain if invasion at its base has occurred. One shouId bear in mind, when deaIing with Iesions in the fundus particuIarIy, that they might be of this character, and avoid disabIing high resections if unnecessary. SimpIe poIypectomy, as we performed in Case I, may not aIways be adequate to provide the pathoIogist with a satisfactory specimen.
fifms were not avaiIabie. Her family history and past history were otherwise non-contributory. Examination revealed marked pallor, obesity and tenderness to deep paIpation in the epigastrium. The red blood count was 2,560,ooo per cu. mm. with 7 gm. (45 per cent) hemoglobin. Gastric anaIysis was not performed. An upper gastrointestinal roentgenogram showed a smooth hemispherical defect on the mid-portion of the lesser curvature, with a 3 cm. centra1 uIceration. (Fig. 4.) The diagnosis made from the x-ray fiIm was carcinoma of the stomach. The possibility of a Ieiomyoma or Ieiomyosarcoma was seriously considered. At operation on October 28, 1957, a smooth, sessile, polypoid tumor measuring 4.5 cm. in its maximum diameter, 3 cm. high and 3.5 cm. across its base was found. (Fig. 5.) SubtotaI gastrectomy was performed. The pathoIogic report was a benign inflammatory fibrinoid polyp (submucosa1 eosinophilic granuIoma of the stomach). (Figs. 6 and 7.) Recovery was uneventful, and the patient has remained well and asymptomatic. COMMENTS
AU inflammatory fibroid poIyps reported to date have been benign. This is in contrast to adenomatous poIyps, which, in a recently collected series, we found 16.6 per cent of the single ones to be mahgnant [3]. In adenomatous poIyps, Hay found over 50 per cent of those over 2 cm. in diameter to be maIignant [5,6]. Both of our patients had large lesions, Ieading to the preoperative diagnosis of maIignancy. Adenomatous polyps are frequentIy muItipIe. In our series of seventy-four coIIected cases, about one-third were muItipIe. OnIy one case of muItipIe inflammatory fibroid poIyps has been reported in the literature [13]. It is common to find carcinoma of the stomach associated with adenomatous poIyps but as yet, no case has been reported with an inffammatory poIyp. The mucosa1 surfaces of inflammatory poIyps frequently uIcerate, Ieading to gradua1 or unrecognized Ioss of bIood as in our Case I, or to massive hemorrhage as in Case II. Pain in inflammatory poIyps was a frequent symptom in those cases Iocated in the antrum or prepyIoric region. In our Case I in which the Iesion was in the fundus, pain was entireIy absent, the principa1 symptoms being due to a severe anemia. WhiIe our two reported Iesions had broad, sessiIe bases, a number of peduncuIated infIammatory polyps have been reported. When Iocated in the prepyIoric region, they
SUMMARY
AND
CONCLUSIONS
Inflammatory fibroid poIyps (eosinophilic granulomas of the stomach) and eosinophilic inMtration are described herein and their distinguishing pathologica characteristics reviewed. EtioIogy, cIinica1 aspects, treatment and prognosis are discussed. Two cases with serious compIications requiring surgery are reported. Since these Iesions are benign in character, surgical treatment need not be as extensive as in adenomatous poIyps, and IocaI excision with the fuI1 thickness of the adjacent stomach wall appears at present to be adequate if the Iesion can be identified as an inflammatory poIyp, with a reasonabIe degree of assurance. REFERENCES
BARRIE, H. J. and ANDERSON,J. C. Hypertrophy of the pylorus in au adult with massive eosinophil infiltration and giant cell reaction. Lancet, 2: 1007-1009, 1948. z. BULLOCK, W. K. and MORAN, E. T. Inflammatory fibroid polyps of the stomach. Cancer, 6: 488-493, 1953. 3. CARLSON, E. and WARD, J. G. Surgical considerations in gastric polyps, polyposis and giant hypertrophic gastritis in 74 cases. Surg., Gynec. ti Obst., 107: 727-738, 1958. I.
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InA ammatory Gastric PoIyps 4. FERRIER,T. and DAVIS, B. Eosinophil infiItration of the stomach and smaII intestine. M. J. Australia, I : 789791, 1957. 5. HAY, L. H. Gastric poIyps, a cIinica1 study. Minnesota Med., 34: 362-364, 1951. 6. HAY, L. H. SurgicaI management of gastric poIyps and adenomas. Surgery, 36: 114-119, 1956. 7. HELWIG, E. G. and RANIER, A. Inflammatory fibroid polyps of the stomach. Surg., Gynec. @ Obst., 96: 355-367, 1953. 8. KAIJSER, R. iiber Hgmangiome des Tractus Gastrointestinahs. Arch. f. klin. Cbir., 187: 351, 1936. Cited by Vanek, J. [IS]. g. MOLONEY, G. E. PyIoric hypertrophy with eosinophi1 infiItration. Lancet, I : 412, 1949. IO. ORR, I. M., MILLER, A. A. and RUSSELL, J. Y. W. Eosinophilic infiItration of the stomach and bowel. Post-Grad. M. J., 30: 485-493, 1954.
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549-551, 1950. 12. RUSIC, J. P., DORSEY, J. M., HUBER, J. L. and ARMSTRONG,S. H., JR. Gastric lesion of Loeffler’s syndrome. Report of a case with inflammatory Iesion simuIating carcinoma. J. A. M. A., 149: 534-537. 1952. 13. SMIRNOV, N. M. GranuIomatous polypi of the stomach. Problems of Oncology, 3: 306311, 1957. 14. SPENCER, J. R., COMFORT, M. W. and DAHLIN, D. C. EosinophiIic infdtration of the stomach and bowe1, associated with pyIoric obstruction and recurrent eosinophiIia. Gastroaterology, 15: 5055’3, ‘950. 15. VANEK, J. Gastric submucosa1 granuIoma with eosinophilic infiltration. Am. J. Path., 25: 397411, 1949.
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