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Intragastric polypus
INTRAGASTRIC REPORT
OF CASE*
DANIEL L. BORDEN, WASHINGTON,
B
ENIGN peduncmated cintragastric poIypus faIIs under the rarer cIassification of stomach tumors. EspeciaIIy
FIG. I.
POLYPUS F.A.C.S.
M.D.,
D.
C.
IncIuded within the range of possibIe comphcations to the stomach is permanent pyloric obstruction, or the tumor may
FIG. 2. Crushing cIamp appIied to pedicle of
Polypus, showing uker.
polypus.
produce the balI-vaIve type of intermittent closure. Intussusception of the stomach produced by a polypus has been reported. SingIe poIyps may become strangulated or the tumor may undergo maIignant degeneration. The presence of a Ione uIcer on the surface of a11 singIe intragastric poIyps accounts for the symptoms most common to this type of tumor, nameIv that of gastric-enteric hemorrhage. Persistent occuIt bIeeding, resuIting in secondary anemia, is the outstanding cIinica1 manifestation of gastric poIyp. Sudden, severe recurrent hemorrhage of an aIarming degree is not an infrequent occurrence and many times Ieads to gastric in\-estigation. The diagnosis of intragastric polyp rests uItimateIy with x-ray examination or operative expIoration. The treatment depends upon surgical intervention with the excision of the poIyp at the base of the pedicIe. If examination
is this true when the peduncuIated mass assumes the size of that in the case to be reported. Because of its reIativeIy infrethis patient with her quent occurrence, history, operative record and postoperative observation is presented for consideration. In rgzr Eusterman made an exhaustive statistica review of benign tumors of the stomach. His concIusions showed carcinoma to be 200 times more frequent than benign tumor. This study incIuded a11 benign growths, myomas, fibromas, angiomas, dermoids, as we11 as singIe polypus of the stomach. Pedunculated myoma or fibroma is usuaIIy seen in the middIe or pyloric portion of the stomach, attached to the posterior or anterior waI1. Of unknown etioIogy, these peduncuIated, freeIy movabIe tumors within a hoIIow muscuIar viscus are subject to mechanica disturbance. This interference may affect the tumor itseIf or its containing viscus.
* Read before the George Washington University Medrcal Society, Dec. 19, 193 I. Motion pictures of the operative procedure were shown in conjunction with this paper. IIS
116
American Journal of Surgery
Borden-Intragastric
at operation discIoses evidence nancy, resection of the stomach considered.
FIG.
of maIigshouId be
Polypus
JANUARY, I 933
Except for abdomina1 tenderness the physica examination was essentially negative. Under supportive treatment her condition,
Stomach containing poIypus held between fingers before opening anterior gastric wall.
3.
REPORT
OF
CASE
H. W. Case No. 53884. Married woman, aged forty-three. Admitted to the ward service at Emergency HospitaI, ApriI 12, 1929. Her famiIy history was negative except that one sister died of hemorrhage of the stomach. Ten years ago the patient had had a sudden She had suffered before gastric hemorrhage. and since that time with stomach trouble, indigestion and cramp-Iike pains in the upper abdomen. For many years she had been under a doctor’s care for genera1 weakness, dizziness and a ringing in the ears. Two years before, she had had to go to bed because of a heart attack. Her present iIIness began the night before admittance to the hospita1 with nausea and weakness. On the morning of ApriI 12 she vomited bIood and passed bright red bIood by rectum. The Emergency ambuIance was caIIed. During her conveyance to the hospital she had another vomiting speI1 when a Iarge quantity of bIood was Iost. Upon admission to the hospita1 at 12 :IO P.M., her temperature was 99.2%., respirations 26, puIse 80 and very weak. The bIood pressure was I 14/74. Fifteen hundred cubic centimeters of gIucose were given intravenousIy at once. A transfusion of 500 C.C. was then given and her condition improved. Her bIood picture two days later was as foIIows: HemogIobin, 37 per cent; R. B. c. 2,160,000; w. B. c. 6500.
FIG. 4. Tumor
removed,
showing actual
size.
another transfusion on April 29, 1929, x-ray examination, which showed growth in the dista1 half “a Iarge intragastric of the stomach attached to the inferior margin by a pedicIe approximateIy 2 cm. in Iength. The growth proper is approximateIy 6 cm. in diameter and it couId be moved upward toward the cardiac end and downward toward the pyIoric end of the stomach for a distance equa1 to the pedicIe of the growth. This is thought to represent a Iarge polyp, the size of which would suggest that it is probabIy degeneration. some maIignant undergoing There was no six-hour gastric residue.” a right rectus On May I, 1929, through incision, the abdomen was expIored for evidence of maIignancy. There being no evidence of gIanduIar enIargement, an intragastric tumor, peduncuIated, the size of a Iemon, was removed through an incision in the anterior waI1 of the stomach. Six days after operation, there deveIoped a respiratory compIication with a
after
permitted
NEW
SERIES VOL. XIX,
No.
I
Borden-Intragastric
slight cough. This was transient and the patient was discharged from the hospital the hospital, hla[\- 24, 1929. Since Ieaving she has worked continuaIIy, has had no gastric symptoms and has gained 40 lb. in weight. Pathological examination discIosed a tumor, “irregularly oval in shape and measuring 7 cm. Iong, 4.5 cm. wide, and 4 cm. thick. It is a light brown in color and very firm in consistency, except at one portion where it shows evidence of softening. It is practicaIIy covered with gastric mucous membrane which is smooth and moderateIy soft in consistency. The norma rugae have practicaIIy disappeared as a result of the upgrowth of the tumor. In the centra1 portion there is a depressed area, irregular in shape which measures I X z cm. in diameter and at one poIe of this area there is a definite uIceration I cm. in diameter which extends into the tissue. The ulceration has ragged edges and extends into a cystic or degenerated cavity which contains a
FIG. 6. X-ray
of stomach
after operation.
dark brown, chocoIate coIored substance. The under surface of the mass is smooth and glistening and apparently has been attached by a broad pedicIe to the walIs of the stomach. It appears to be definiteIy surrounded by a complete fibrous connective tissue capsuIe.” [Concluded
Polypus
American
Journal
of Surg.cry
II?
“Microscopic examination shows the mucous membrane to be markedIy thinned, apparentIy as a result of compression atrophy; this is
FIG. 5. Tumor opened after removal.
associated with a reIative submucous ceI1 infiltration except in one portion definite uIceration has taken place.
FIG.
7. X-ray
showing clearIy pedunculated within stomach.
round where Imme-
tumor
diateIy beneath this are found atrophic strands of smooth muscle fibers interspersed in various areas with dense bands of fibrous connective tissue, a11 of which is infiItrated with a reIative number of smaI1 round ceIIs. In some areas the muscIe fibers show definite proIiferation. on p. 123.)
OF CASE*
DANIEL L. BORDEN, WASHINGTON,
B
ENIGN peduncmated cintragastric poIypus faIIs under the rarer cIassification of stomach tumors. EspeciaIIy
FIG. I.
POLYPUS F.A.C.S.
M.D.,
D.
C.
IncIuded within the range of possibIe comphcations to the stomach is permanent pyloric obstruction, or the tumor may
FIG. 2. Crushing cIamp appIied to pedicle of
Polypus, showing uker.
polypus.
produce the balI-vaIve type of intermittent closure. Intussusception of the stomach produced by a polypus has been reported. SingIe poIyps may become strangulated or the tumor may undergo maIignant degeneration. The presence of a Ione uIcer on the surface of a11 singIe intragastric poIyps accounts for the symptoms most common to this type of tumor, nameIv that of gastric-enteric hemorrhage. Persistent occuIt bIeeding, resuIting in secondary anemia, is the outstanding cIinica1 manifestation of gastric poIyp. Sudden, severe recurrent hemorrhage of an aIarming degree is not an infrequent occurrence and many times Ieads to gastric in\-estigation. The diagnosis of intragastric polyp rests uItimateIy with x-ray examination or operative expIoration. The treatment depends upon surgical intervention with the excision of the poIyp at the base of the pedicIe. If examination
is this true when the peduncuIated mass assumes the size of that in the case to be reported. Because of its reIativeIy infrethis patient with her quent occurrence, history, operative record and postoperative observation is presented for consideration. In rgzr Eusterman made an exhaustive statistica review of benign tumors of the stomach. His concIusions showed carcinoma to be 200 times more frequent than benign tumor. This study incIuded a11 benign growths, myomas, fibromas, angiomas, dermoids, as we11 as singIe polypus of the stomach. Pedunculated myoma or fibroma is usuaIIy seen in the middIe or pyloric portion of the stomach, attached to the posterior or anterior waI1. Of unknown etioIogy, these peduncuIated, freeIy movabIe tumors within a hoIIow muscuIar viscus are subject to mechanica disturbance. This interference may affect the tumor itseIf or its containing viscus.
* Read before the George Washington University Medrcal Society, Dec. 19, 193 I. Motion pictures of the operative procedure were shown in conjunction with this paper. IIS
116
American Journal of Surgery
Borden-Intragastric
at operation discIoses evidence nancy, resection of the stomach considered.
FIG.
of maIigshouId be
Polypus
JANUARY, I 933
Except for abdomina1 tenderness the physica examination was essentially negative. Under supportive treatment her condition,
Stomach containing poIypus held between fingers before opening anterior gastric wall.
3.
REPORT
OF
CASE
H. W. Case No. 53884. Married woman, aged forty-three. Admitted to the ward service at Emergency HospitaI, ApriI 12, 1929. Her famiIy history was negative except that one sister died of hemorrhage of the stomach. Ten years ago the patient had had a sudden She had suffered before gastric hemorrhage. and since that time with stomach trouble, indigestion and cramp-Iike pains in the upper abdomen. For many years she had been under a doctor’s care for genera1 weakness, dizziness and a ringing in the ears. Two years before, she had had to go to bed because of a heart attack. Her present iIIness began the night before admittance to the hospita1 with nausea and weakness. On the morning of ApriI 12 she vomited bIood and passed bright red bIood by rectum. The Emergency ambuIance was caIIed. During her conveyance to the hospital she had another vomiting speI1 when a Iarge quantity of bIood was Iost. Upon admission to the hospita1 at 12 :IO P.M., her temperature was 99.2%., respirations 26, puIse 80 and very weak. The bIood pressure was I 14/74. Fifteen hundred cubic centimeters of gIucose were given intravenousIy at once. A transfusion of 500 C.C. was then given and her condition improved. Her bIood picture two days later was as foIIows: HemogIobin, 37 per cent; R. B. c. 2,160,000; w. B. c. 6500.
FIG. 4. Tumor
removed,
showing actual
size.
another transfusion on April 29, 1929, x-ray examination, which showed growth in the dista1 half “a Iarge intragastric of the stomach attached to the inferior margin by a pedicIe approximateIy 2 cm. in Iength. The growth proper is approximateIy 6 cm. in diameter and it couId be moved upward toward the cardiac end and downward toward the pyIoric end of the stomach for a distance equa1 to the pedicIe of the growth. This is thought to represent a Iarge polyp, the size of which would suggest that it is probabIy degeneration. some maIignant undergoing There was no six-hour gastric residue.” a right rectus On May I, 1929, through incision, the abdomen was expIored for evidence of maIignancy. There being no evidence of gIanduIar enIargement, an intragastric tumor, peduncuIated, the size of a Iemon, was removed through an incision in the anterior waI1 of the stomach. Six days after operation, there deveIoped a respiratory compIication with a
after
permitted
NEW
SERIES VOL. XIX,
No.
I
Borden-Intragastric
slight cough. This was transient and the patient was discharged from the hospital the hospital, hla[\- 24, 1929. Since Ieaving she has worked continuaIIy, has had no gastric symptoms and has gained 40 lb. in weight. Pathological examination discIosed a tumor, “irregularly oval in shape and measuring 7 cm. Iong, 4.5 cm. wide, and 4 cm. thick. It is a light brown in color and very firm in consistency, except at one portion where it shows evidence of softening. It is practicaIIy covered with gastric mucous membrane which is smooth and moderateIy soft in consistency. The norma rugae have practicaIIy disappeared as a result of the upgrowth of the tumor. In the centra1 portion there is a depressed area, irregular in shape which measures I X z cm. in diameter and at one poIe of this area there is a definite uIceration I cm. in diameter which extends into the tissue. The ulceration has ragged edges and extends into a cystic or degenerated cavity which contains a
FIG. 6. X-ray
of stomach
after operation.
dark brown, chocoIate coIored substance. The under surface of the mass is smooth and glistening and apparently has been attached by a broad pedicIe to the walIs of the stomach. It appears to be definiteIy surrounded by a complete fibrous connective tissue capsuIe.” [Concluded
Polypus
American
Journal
of Surg.cry
II?
“Microscopic examination shows the mucous membrane to be markedIy thinned, apparentIy as a result of compression atrophy; this is
FIG. 5. Tumor opened after removal.
associated with a reIative submucous ceI1 infiltration except in one portion definite uIceration has taken place.
FIG.
7. X-ray
showing clearIy pedunculated within stomach.
round where Imme-
tumor
diateIy beneath this are found atrophic strands of smooth muscle fibers interspersed in various areas with dense bands of fibrous connective tissue, a11 of which is infiItrated with a reIative number of smaI1 round ceIIs. In some areas the muscIe fibers show definite proIiferation. on p. 123.)