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Primary gastric melanoma presenting as a nonhealing ulcer
Brief Reports
W Alazmi, O Nehme, J Regalado, et al.
Primary gastric melanoma presenting as a nonhealing ulcer Malignant melanoma most commonly arises in the skin, but primary melanoma can also arise from the mucosa of the GI tract. The vast majority of GI melanomas are metastases from a cutaneous primary tumor. Melanoma of the stomach is a rarity among primary melanomas. Reported here is the case of a patient with a primary gastric melanoma who presented with a nonhealing gastric ulcer. To our knowledge, this is the first case of a primary gastric melanoma reported from the United States. Case report. A 58-year-old man with a complaint of chronic fatigue was found to have iron deficiency anemia. The patient also reported intermittent epigastric pain of 2 years’ duration that was partially relieved by antacids. H denied ingestion of nonsteroidal anti-inflammatory medications and had noted a 20-pound weight loss over the preceding 3 months. A fecal occult blood test had positive results, but the remainder of the physical examination wa unremarkable. Laboratory data were as follows: hematocrit, 24% (normal 37%-49%); mean corpuscular volume, 74 fL (78-100 fL); serum iron level, 20 g/dL (30-160 g/dL); and total iron-binding capacity, 350 g/dL (228-428 g/dL). Colonoscopy was negative, but EGD disclosed a 2-cm ulcer in the gastric fundus, surrounded by thickened mucosal folds (Fig. 1). Biopsies revealed chronic gastritis with no evidence of Helicobacter pylori infection. EGD was repeated after 8 weeks of therapy with omeprazole (20 mg twice daily). Theree was no change in the size of the ulcer, and biopsies disclosed a well-demarcated, sheet-like tumor consisting of large polygonal malignant cells with large nuclei and eosinophlic cytoplasm. An immunoperoxidase stain for S-100 proteins showed positive results (Fig. 2). The tumor cells were also positive for tyrosinase and melanin-A, consistent with melanoma, and negative for keratin, epithelial membrane antigen (EMA), and leukocyte common antigen, which ruled out carcinoma and lymphoma. CT of the abdomen demon-
Figure 1. Endoscopic view of 2-cm ulcer in gastric fundus surrounded by thickened mucosal folds.
Reprint requests: Waleed M. Alazmi, MD, Division of Gastroenterology, Department of Medicine, University of Miami School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., South wing Room 220, Miami, FL 33136. Copyright © 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067/mge.2003.120
Figure 2. Photomicrograph of endoscopic biopsy showing strong staining of large tumor cells with S-100 (Immunoperoxidase stain, orig. mag. ×20). strated a large mass in the left lateral posterior aspect of the stomach, about 4 cm in diameter (Fig. 3). Ophthalmologic and dermatologic examinations were negative. In addition, anoscopy, chest CT, and small-bowel barium contrast radiography were negative for a primary melanoma. VOLUME 57, NO. 3, 2003
GASTROINTESTINAL ENDOSCOPY
431
W Alazmi, O Nehme, J Regalado, et al.
Figure 3. Abdominal CT showing large mass involving left lateral posterior aspect of stomach (arrow) (S, spleen). The patient underwent partial gastrectomy and splenectomy. Histopathologic evaluation of the resection specimen was consistent with a malignant melanoma extending through the muscularis propria but not involving the serosa. Lymph nodes were negative for metastases, and complete excision of the ulcerated lesion was reported. Two years after the surgery the patient is doing well and has completed a 12-month course of adjuvant interferon therapy (5 million IU 3 times/week). Follow-up EGD did not reveal any signs of recurrence. Discussion. Noncutaneous melanoma represents a rare form of melanoma that arises from ocular, mucosal, or unknown primary sites. In a review of 84,836 cases of melanoma from the National Cancer Data Base entered between 1985 and 1994, 91.2% were cutaneous, 5.2% ocular, 1.3% mucosal, and 2.2% of unknown primary. In the United States the incidence of cutaneous melanoma continues to rise at a rate higher than that for any other form of human cancer. The incidence of noncutaneous melanoma remains stable.1 Malignant melanoma can arise in GI mucosal sites including the esophagus,2,3 anorectum,4 and small bowel.5,6 Rarely, cases of primary melanoma of the stomach have been reported.7-9 Criteria for the diagnosis of a primary melanoma include absence of concurrent lesions and no history of removal of a melanoma or atypical melanocytic lesion from the skin or other organ.4 It is well recognized that melanocytic nevi and melanomas may undergo regression and that the regression may be partial or complete.10 However, there are no data as to how many melanomas regress completely without leaving metastasis. The exact mechanism of regression remains unknown and difficult to study.11 Carefully performed histologic studies confirm the presence of melanocytes in the mucosa of the GI tract, most commonly the anal canal. More recent studies have included immunohistochemical staining with HMB-45 and S-100, and further confirm the presence of melanocytes in these regions.12 There is extensive knowledge regarding the etiology and epidemiology of 432
GASTROINTESTINAL ENDOSCOPY
Brief Reports
cutaneous melanoma; however, little similar information is available for primary GI melanomas. Exposure to ultraviolet radiation is a major predisposing factor to cutaneous melanoma. The occurrence of melanomas in areas never exposed to sunlight, such as GI melanomas, may provide important insights into the pathogenesis of melanoma in general.13 Patients with mucosal melanomas are generally older than those with cutaneous lesions, and are more likely to be women and black.14 The female genital tract is proportionally the most common site of these lesions and this accounts for the female to male gender disproportion.15 Melanomas that arise on mucosal surfaces appear to be more aggressive and are associated with a worse prognosis than cutaneous melanomas. This poorer prognosis may be related to delay in diagnosis, an inherently more aggressive behavior of mucosal melanomas, or earlier dissemination because of the rich lymphatic and vascular supply of GI tract mucosa.16 In some series, tumor thickness of less than 2 mm has been associated with improved survival; however, the majority of patients have thicker lesions, and the small number of patients described in most series precludes convincing correlation.15 Manifestations of primary malignant melanoma of the stomach are similar to those of other gastric tumors with anemia and weight loss being most common. History and examination usually reveal only evidence for weight loss. Barium contrast radiography and endoscopy are both reasonable conventional initial diagnostic approaches. CT of the abdomen may reveal the tumor or evidence of lymph node metastases. Endoscopy with tissue sampling often provides a definitive diagnosis. Immunohistochemical stains for S-100 and HMB-45 have increased the diagnostic sensitivity of the biopsy and cytologic evaluation. Primary GI mucosal melanoma is a rare disease that can cause significant morbidity and mortality. Spontaneous regression of cutaneous melanoma with subsequent metastasis has been reported.10 Melanoma should be considered in the differential diagnosis of primary GI malignancy, and when idiopathic, large, slow-healing gastric ulcerations are encountered. The case presented here is that of a patient with an exceptionally rare entity that was considered a primary gastric melanoma. In this small group of patients with primary GI mucosal melanoma, early detection and surgical intervention are key to long-term cure. Waleed M. Alazmi, MD Omar S. Nehme, MD Jacinto J. Regalado, MD Arvey I. Rogers, MD University of Miami Miami Beach, Florida REFERENCES 1. Chang AE, Karnell LH, Manck HR. The national cancer database reports on cutaneous and non-cutaneous melanoma: a summary of 84,836 cases from the past decade. Cancer 1998; 8:1665-78. 2. Chalkiadakis MD, Wihlm JM, Morand G, Weill-Bousson M, Witz JP. Primary malignant melanoma of the esophagus. Ann Thorac Surg 1985;39:473-5. 3. Stranks G, Mathai J, Rowe-Jones D. Primary malignant VOLUME 57, NO. 3, 2003
Brief Reports
4.
5.
6.
7. 8.
9. 10. 11. 12. 13.
14.
15.
16.
melanoma of the esophagus: case report and review of surgical pathology. Gut 1991;32:828-9. Christova S, Meinhard K, Mihailov I, Alexiev B. Three cases of primary malignant melanoma of the alimentary tact. Gen Diagnostic Pathol 1996;142:63-7. Kadivar TF, Vanek VW, Krishnan EU. Primary malignant melanoma of the small bowel: a case study. Am Surg 1992; 58:418-21. Sachs DL, Lowe L, Chang AE, Carson E, Johnson TM. Do primary small intestinal melanomas exist? Report of a case. J Am Acad Dermatol 1999;41:1042-4. Chandler A, Jones G. Malignant melanoma of the gastrointestinal tract: a case report. Am Surg 1951;17:719-21. Rao GM, Satyanarayana Y, Janaki M, Hayath MS. Primary melanocarcinoma of stomach [abstract]. Indian J Gastroenterol 1999;18:176. Macak J. Melanoma of the stomach: reality & fiction? Pathologica 1998;90:388-90. Dicic Y. Spontaneous regression of cutaneous melanoma with subsequent metastasis. J Oral Maxillofac Surg 2002;60:588-91. Printz C. Spontaneous regression of melanoma may offer insight into cancer immunology. J Nat Cancer Inst 2001;93:1047-8. Clemmensen OJ, Fenger C: Melanocytes in the anal canal epithelium. Histopathology 1991;18:237-41. Schuchter LM, Green R, Fraker D. Primary and metastatic diseases in malignant melanoma of the gastrointestinal tract. Curr Opin Oncol 2000;12:181-5. Sutherland CM, Chmiel JS, Henson DE, Winchester DP. Patient characteristics, methods of diagnosis, and treatment of mucous membrane melanoma in the United States of America. S Am Coll Surg 1994;179:561-6. DeMatos P, Tyler DS, Seigler HF. Malignant melanoma of the mucous membranes: a review of 119 cases. Ann Surg Oncol 1998;5:733-42. Wong JH, Cagle LA, Storm FK, Morton, DL. Natural history of surgically treated mucosal melanoma. Am J Surg 1987; 154:54-7.
Endoscopic hemoclip application for the treatment of a large gastric polyp causing intermittent outlet obstruction Gastric polyps are usually incidental findings at endoscopy and of little clinical significance. They are seen in about 2% of endoscopies and are even less frequent, approximately 0.15%, in autopsy series.1 Hyperplastic polyps account for 80% to 85% of gastric polyps and constitute the most common variety.2 They are usually located in the antrum or at the junction of the antrum and body. Most are small; only about 10% to 15% are 2 cm or larger. It is these large polyps that are clinically significant because of chronic occult bleeding and anemia or intermittent gastric outlet obstruction.3 The hemoclip has recently been added to the armamentarium of endoscopic hemostatic devices.4-6 Several studies Reprint requests: A. A. Mihas, MD, McGuire Veterans Affairs Medical Center (111N), 1201 Broad Rock Blvd., Richmond, VA 23249. Copyright © 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067/mge.2003.119 VOLUME 57, NO. 3, 2003
S Abou-Assi, A Mihas, R Joseph, et al.
Figure 1. Barium contrast radiograph showing large polyp (arrows) in antrum of stomach. have shown that endoscopic hemoclip application is useful for achieving hemostasis in critically ill patients with severe GI hemorrhage.7-10 To our knowledge, endoscopic hemoclip placement for the resection of large polyps has not been reported. A case is described of a large hyperplastic polyp that caused intermittent gastric outlet obstruction and was treated with an unusual endoscopic approach. Case report. A 41-year-old white woman was referred for evaluation of intermittent epigastric pain associated with nausea and vomiting. Five years earlier a diagnosis of acute myelocytic leukemia was made. After several unsuccessful courses of chemotherapy, the patient underwent bone marrow transplantation. The post-transplantation course was complicated by graft versus host disease involving multiple organs including the skin, GI tract, liver, and the lungs. The patient was oxygen-dependent and had an extremely poor effort tolerance. The pain was described as cramping, localized in the epigastrium, and usually precipitated by ingestion of solid food. She was better able to tolerate liquids or a pureed diet. The symptoms were attributed to the multiple medications being taking for leukemia. A barium contrast upper GI series revealed a large polypoid lesion in the antrum of the stomach near the pylorus (Fig. 1). EGD confirmed the radiographic findings. There was a moderate amount of retained food debris in the stomach, and several polyps were present in the antrum, the largest being about 20 mm × 40 mm in size with a thick stalk (Fig. 2). This latter polyp was noted to intussuscept into the duodenum with gastric contractions. Biopsies demonstrated the polyp to be hyperplastic (Fig. 3). It was concluded that the large polyp was playing a major role in the GI symptomatology, and thus a decision was made for polypectomy. The thick stalk as well as profound thrombocytopenia was thought to preclude electrosurgical snare polypectomy. Instead, 3 endoclips (HX-3/4) GASTROINTESTINAL ENDOSCOPY
433
W Alazmi, O Nehme, J Regalado, et al.
Primary gastric melanoma presenting as a nonhealing ulcer Malignant melanoma most commonly arises in the skin, but primary melanoma can also arise from the mucosa of the GI tract. The vast majority of GI melanomas are metastases from a cutaneous primary tumor. Melanoma of the stomach is a rarity among primary melanomas. Reported here is the case of a patient with a primary gastric melanoma who presented with a nonhealing gastric ulcer. To our knowledge, this is the first case of a primary gastric melanoma reported from the United States. Case report. A 58-year-old man with a complaint of chronic fatigue was found to have iron deficiency anemia. The patient also reported intermittent epigastric pain of 2 years’ duration that was partially relieved by antacids. H denied ingestion of nonsteroidal anti-inflammatory medications and had noted a 20-pound weight loss over the preceding 3 months. A fecal occult blood test had positive results, but the remainder of the physical examination wa unremarkable. Laboratory data were as follows: hematocrit, 24% (normal 37%-49%); mean corpuscular volume, 74 fL (78-100 fL); serum iron level, 20 g/dL (30-160 g/dL); and total iron-binding capacity, 350 g/dL (228-428 g/dL). Colonoscopy was negative, but EGD disclosed a 2-cm ulcer in the gastric fundus, surrounded by thickened mucosal folds (Fig. 1). Biopsies revealed chronic gastritis with no evidence of Helicobacter pylori infection. EGD was repeated after 8 weeks of therapy with omeprazole (20 mg twice daily). Theree was no change in the size of the ulcer, and biopsies disclosed a well-demarcated, sheet-like tumor consisting of large polygonal malignant cells with large nuclei and eosinophlic cytoplasm. An immunoperoxidase stain for S-100 proteins showed positive results (Fig. 2). The tumor cells were also positive for tyrosinase and melanin-A, consistent with melanoma, and negative for keratin, epithelial membrane antigen (EMA), and leukocyte common antigen, which ruled out carcinoma and lymphoma. CT of the abdomen demon-
Figure 1. Endoscopic view of 2-cm ulcer in gastric fundus surrounded by thickened mucosal folds.
Reprint requests: Waleed M. Alazmi, MD, Division of Gastroenterology, Department of Medicine, University of Miami School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Ave., South wing Room 220, Miami, FL 33136. Copyright © 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067/mge.2003.120
Figure 2. Photomicrograph of endoscopic biopsy showing strong staining of large tumor cells with S-100 (Immunoperoxidase stain, orig. mag. ×20). strated a large mass in the left lateral posterior aspect of the stomach, about 4 cm in diameter (Fig. 3). Ophthalmologic and dermatologic examinations were negative. In addition, anoscopy, chest CT, and small-bowel barium contrast radiography were negative for a primary melanoma. VOLUME 57, NO. 3, 2003
GASTROINTESTINAL ENDOSCOPY
431
W Alazmi, O Nehme, J Regalado, et al.
Figure 3. Abdominal CT showing large mass involving left lateral posterior aspect of stomach (arrow) (S, spleen). The patient underwent partial gastrectomy and splenectomy. Histopathologic evaluation of the resection specimen was consistent with a malignant melanoma extending through the muscularis propria but not involving the serosa. Lymph nodes were negative for metastases, and complete excision of the ulcerated lesion was reported. Two years after the surgery the patient is doing well and has completed a 12-month course of adjuvant interferon therapy (5 million IU 3 times/week). Follow-up EGD did not reveal any signs of recurrence. Discussion. Noncutaneous melanoma represents a rare form of melanoma that arises from ocular, mucosal, or unknown primary sites. In a review of 84,836 cases of melanoma from the National Cancer Data Base entered between 1985 and 1994, 91.2% were cutaneous, 5.2% ocular, 1.3% mucosal, and 2.2% of unknown primary. In the United States the incidence of cutaneous melanoma continues to rise at a rate higher than that for any other form of human cancer. The incidence of noncutaneous melanoma remains stable.1 Malignant melanoma can arise in GI mucosal sites including the esophagus,2,3 anorectum,4 and small bowel.5,6 Rarely, cases of primary melanoma of the stomach have been reported.7-9 Criteria for the diagnosis of a primary melanoma include absence of concurrent lesions and no history of removal of a melanoma or atypical melanocytic lesion from the skin or other organ.4 It is well recognized that melanocytic nevi and melanomas may undergo regression and that the regression may be partial or complete.10 However, there are no data as to how many melanomas regress completely without leaving metastasis. The exact mechanism of regression remains unknown and difficult to study.11 Carefully performed histologic studies confirm the presence of melanocytes in the mucosa of the GI tract, most commonly the anal canal. More recent studies have included immunohistochemical staining with HMB-45 and S-100, and further confirm the presence of melanocytes in these regions.12 There is extensive knowledge regarding the etiology and epidemiology of 432
GASTROINTESTINAL ENDOSCOPY
Brief Reports
cutaneous melanoma; however, little similar information is available for primary GI melanomas. Exposure to ultraviolet radiation is a major predisposing factor to cutaneous melanoma. The occurrence of melanomas in areas never exposed to sunlight, such as GI melanomas, may provide important insights into the pathogenesis of melanoma in general.13 Patients with mucosal melanomas are generally older than those with cutaneous lesions, and are more likely to be women and black.14 The female genital tract is proportionally the most common site of these lesions and this accounts for the female to male gender disproportion.15 Melanomas that arise on mucosal surfaces appear to be more aggressive and are associated with a worse prognosis than cutaneous melanomas. This poorer prognosis may be related to delay in diagnosis, an inherently more aggressive behavior of mucosal melanomas, or earlier dissemination because of the rich lymphatic and vascular supply of GI tract mucosa.16 In some series, tumor thickness of less than 2 mm has been associated with improved survival; however, the majority of patients have thicker lesions, and the small number of patients described in most series precludes convincing correlation.15 Manifestations of primary malignant melanoma of the stomach are similar to those of other gastric tumors with anemia and weight loss being most common. History and examination usually reveal only evidence for weight loss. Barium contrast radiography and endoscopy are both reasonable conventional initial diagnostic approaches. CT of the abdomen may reveal the tumor or evidence of lymph node metastases. Endoscopy with tissue sampling often provides a definitive diagnosis. Immunohistochemical stains for S-100 and HMB-45 have increased the diagnostic sensitivity of the biopsy and cytologic evaluation. Primary GI mucosal melanoma is a rare disease that can cause significant morbidity and mortality. Spontaneous regression of cutaneous melanoma with subsequent metastasis has been reported.10 Melanoma should be considered in the differential diagnosis of primary GI malignancy, and when idiopathic, large, slow-healing gastric ulcerations are encountered. The case presented here is that of a patient with an exceptionally rare entity that was considered a primary gastric melanoma. In this small group of patients with primary GI mucosal melanoma, early detection and surgical intervention are key to long-term cure. Waleed M. Alazmi, MD Omar S. Nehme, MD Jacinto J. Regalado, MD Arvey I. Rogers, MD University of Miami Miami Beach, Florida REFERENCES 1. Chang AE, Karnell LH, Manck HR. The national cancer database reports on cutaneous and non-cutaneous melanoma: a summary of 84,836 cases from the past decade. Cancer 1998; 8:1665-78. 2. Chalkiadakis MD, Wihlm JM, Morand G, Weill-Bousson M, Witz JP. Primary malignant melanoma of the esophagus. Ann Thorac Surg 1985;39:473-5. 3. Stranks G, Mathai J, Rowe-Jones D. Primary malignant VOLUME 57, NO. 3, 2003
Brief Reports
4.
5.
6.
7. 8.
9. 10. 11. 12. 13.
14.
15.
16.
melanoma of the esophagus: case report and review of surgical pathology. Gut 1991;32:828-9. Christova S, Meinhard K, Mihailov I, Alexiev B. Three cases of primary malignant melanoma of the alimentary tact. Gen Diagnostic Pathol 1996;142:63-7. Kadivar TF, Vanek VW, Krishnan EU. Primary malignant melanoma of the small bowel: a case study. Am Surg 1992; 58:418-21. Sachs DL, Lowe L, Chang AE, Carson E, Johnson TM. Do primary small intestinal melanomas exist? Report of a case. J Am Acad Dermatol 1999;41:1042-4. Chandler A, Jones G. Malignant melanoma of the gastrointestinal tract: a case report. Am Surg 1951;17:719-21. Rao GM, Satyanarayana Y, Janaki M, Hayath MS. Primary melanocarcinoma of stomach [abstract]. Indian J Gastroenterol 1999;18:176. Macak J. Melanoma of the stomach: reality & fiction? Pathologica 1998;90:388-90. Dicic Y. Spontaneous regression of cutaneous melanoma with subsequent metastasis. J Oral Maxillofac Surg 2002;60:588-91. Printz C. Spontaneous regression of melanoma may offer insight into cancer immunology. J Nat Cancer Inst 2001;93:1047-8. Clemmensen OJ, Fenger C: Melanocytes in the anal canal epithelium. Histopathology 1991;18:237-41. Schuchter LM, Green R, Fraker D. Primary and metastatic diseases in malignant melanoma of the gastrointestinal tract. Curr Opin Oncol 2000;12:181-5. Sutherland CM, Chmiel JS, Henson DE, Winchester DP. Patient characteristics, methods of diagnosis, and treatment of mucous membrane melanoma in the United States of America. S Am Coll Surg 1994;179:561-6. DeMatos P, Tyler DS, Seigler HF. Malignant melanoma of the mucous membranes: a review of 119 cases. Ann Surg Oncol 1998;5:733-42. Wong JH, Cagle LA, Storm FK, Morton, DL. Natural history of surgically treated mucosal melanoma. Am J Surg 1987; 154:54-7.
Endoscopic hemoclip application for the treatment of a large gastric polyp causing intermittent outlet obstruction Gastric polyps are usually incidental findings at endoscopy and of little clinical significance. They are seen in about 2% of endoscopies and are even less frequent, approximately 0.15%, in autopsy series.1 Hyperplastic polyps account for 80% to 85% of gastric polyps and constitute the most common variety.2 They are usually located in the antrum or at the junction of the antrum and body. Most are small; only about 10% to 15% are 2 cm or larger. It is these large polyps that are clinically significant because of chronic occult bleeding and anemia or intermittent gastric outlet obstruction.3 The hemoclip has recently been added to the armamentarium of endoscopic hemostatic devices.4-6 Several studies Reprint requests: A. A. Mihas, MD, McGuire Veterans Affairs Medical Center (111N), 1201 Broad Rock Blvd., Richmond, VA 23249. Copyright © 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 doi:10.1067/mge.2003.119 VOLUME 57, NO. 3, 2003
S Abou-Assi, A Mihas, R Joseph, et al.
Figure 1. Barium contrast radiograph showing large polyp (arrows) in antrum of stomach. have shown that endoscopic hemoclip application is useful for achieving hemostasis in critically ill patients with severe GI hemorrhage.7-10 To our knowledge, endoscopic hemoclip placement for the resection of large polyps has not been reported. A case is described of a large hyperplastic polyp that caused intermittent gastric outlet obstruction and was treated with an unusual endoscopic approach. Case report. A 41-year-old white woman was referred for evaluation of intermittent epigastric pain associated with nausea and vomiting. Five years earlier a diagnosis of acute myelocytic leukemia was made. After several unsuccessful courses of chemotherapy, the patient underwent bone marrow transplantation. The post-transplantation course was complicated by graft versus host disease involving multiple organs including the skin, GI tract, liver, and the lungs. The patient was oxygen-dependent and had an extremely poor effort tolerance. The pain was described as cramping, localized in the epigastrium, and usually precipitated by ingestion of solid food. She was better able to tolerate liquids or a pureed diet. The symptoms were attributed to the multiple medications being taking for leukemia. A barium contrast upper GI series revealed a large polypoid lesion in the antrum of the stomach near the pylorus (Fig. 1). EGD confirmed the radiographic findings. There was a moderate amount of retained food debris in the stomach, and several polyps were present in the antrum, the largest being about 20 mm × 40 mm in size with a thick stalk (Fig. 2). This latter polyp was noted to intussuscept into the duodenum with gastric contractions. Biopsies demonstrated the polyp to be hyperplastic (Fig. 3). It was concluded that the large polyp was playing a major role in the GI symptomatology, and thus a decision was made for polypectomy. The thick stalk as well as profound thrombocytopenia was thought to preclude electrosurgical snare polypectomy. Instead, 3 endoclips (HX-3/4) GASTROINTESTINAL ENDOSCOPY
433