LETTERS TO THE EDITOR

 

Ball valve syndrome caused by a giant gastric Vanek's tumor

 

 

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Key words: Ball valve syndrome. Inflammatory fibroid polyp. Vanek's tumor. Endoscopy.

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Dear Editor,

Inflammatory fibroid polyps (Vanek's tumor) are rare, accounting for 0.1% of all gastric polyps (1). This letter describes an unusual case of an intermittent gastric outlet obstruction by a large Vanek's tumor.

 

Case report

A 70-year-old male, who previously underwent surgery for colorectal cancer, was referred to our department for management of a gastric polypoid lesion detected on a computed tomography (CT) scan (Fig. 1A). He reported several months of intermittent postprandial bloating, nausea and vomiting. Physical examination and laboratory tests were unremarkable. Esophago-gastro-duodenoscopy revealed a giant pedunculated polyp (50 mm) arising from the antrum, protruding through the pylorus into the duodenal bulb and causing gastric outlet obstruction ("scarf-ring sign") (Fig. 1 B and C). Given the obstructive symptoms, we performed an endoscopic resection with a monopolar snare polypectomy after the injection of the base with adrenaline. Nevertheless, arterial spurting hemorrhage occurred from the vessel in the scar, which was successfully controlled with the placement of endoclips. Histopathological findings were consistent with a Vanek's tumor (Fig. 1D).

 

 

Discussion

Inflammatory fibroid polyps (IFPs) are rare mesenchymal tumors that arise in the submucosa of the gastrointestinal tract. Most of the IFPs are asymptomatic and found in the stomach (2). However, if they reach a significant size, it can lead to gastric outlet obstruction, the so-called "ball valve syndrome" (3). Since there are no pathognomonic endoscopic or ultrasonographic features, the diagnosis is made based on histopathology, requiring surgical or endoscopic resection. Several factors should be considered when making the decision: type, size and location of the polyp, patient's health status, and local expertise. Endoscopic resection of larger pedunculated polyps is technically complex, while surgical excision is not suitable for high risk patients. Although the optimal management strategies have not yet been defined, our case demonstrates the current utility of diagnostic and therapeutic monopolar snare polypectomy in a symptomatic gastric IFP.

 

Cláudio Martins, Élia Gamito and Ana Paula Oliveira
Department of Gastroenterology. Centro Hospitalar de Setúbal.
Hospital de São Bernardo. Setúbal, Portugal

 

References

1. Stolte M, Sticht T, Eidt S, et al. Frequency, location, and age and sex distribution of various types of gastric polyp. Endoscopy 1994; 26(8):659-65. DOI: 10.1055/s-2007-1009061.         [ Links ]

2. Liu TC, Lin MT, Montgomery EA, et al. Inflammatory fibroid polyps of the gastrointestinal tract: Spectrum of clinical, morphologic, and immunohistochemistry features. Am J Surg Pathol 2013;37:586-92. DOI: 10.1097/PAS.0b013e31827ae11e.         [ Links ]

3. Yazumi S, Nakase H, Matsushima Y, et al. The "scarf-ring sign" of ball valve syndrome. Gastrointest Endosc 2002;55:560. DOI: 10.1067/mge.2002.122798.         [ Links ]