An ugly polyp !

This nodule has developed at the gastric anastomosis in an elderly patient who had undergone a Billroth II procedure some 30 years ago for peptic ulcer disease.  Initial biopsies (4 samples) have indicated that it is a hyperplastic polyp. 
HOW WOULD YOU MANAGE THIS CASE?

■ Reassure and discharge the patient

INCORRECT!

■ Keep lesion under surveillance

INCORRECT

■ Take another set of biopsies

INCORRECT!

■ Remove the lesion endoscopically

ABSOLUTELY!

■ Refer patient for surgery

INCORRECT!

explanation

For some reason, histopathologists often find it difficult to report on nodules sampled at a gastric stoma. In this case, I actually removed the polyp and took a full set of biopsies from around the stoma.  The histology wasn't entirely clear cut.  A couple of our histopathologists thought that the lesion was benign whilst three thought that it contained a small spot of intramucosal cancer. 

My endoscopic diagnosis was of a malignant polyp as it seemed a little too irregular with a funny deep cleft for being a simple inflammatory polyp.