Elimination of Recurrent Hyperplastic Polyps by Eradication of Helicobacter pylori

Marshall and colleagues' seminal publication in 1985 [1] suggesting a causal relation between Helicobacter pylori and chronic gastritis and peptic ulceration was greeted with considerable skepticism in the medical community. However, subsequent reports have confirmed this association [2], but little has been written about the potential causal relation of H. pylori infection to hyperplastic gastric polyps [3]. We report the disappearance of active gastritis and multiple recurrences of hyperplastic gastric polyps after elimination of H. pylori during a 7-year study. Case Report A 56-year-old man had iron deficiency anemia after routine blood testing in November 1984. Subsequently, an upper gastrointestinal series showed multiple filling defects interpreted as giant gastric ulcers. After an 8-week course of ranitidine therapy in 1984, no radiographic improvement was noted, and an endoscopic examination showed what appeared to be a friable mass in the midportion of the stomach. Because of the size of the mass, exploratory laparotomy and gastrotomy were done in April 1985. Findings at exploration included multiple gastric polyps with a friable overlying mucosa. Multiple polyps were excised, and a full-thickness gastric biopsy specimen was obtained. Pathologic results showed the polyps to vary in size from 0.8 cm to 2.6 cm in diameter. They were generally red in color with a smooth surface that had some areas of erosion. Histologic results showed elongation and hyperplasia of the foveolae with a single cell layer of lining epithelium. Within the glands a substantial cellular infiltrate was noted consisting of plasma cells, eosinophils, and mucinous cells (Figure 1). Figure 1. Electrocardiogram results for the recovery period after a maximal exercise stress test for patient 1. Endoscopy results again showed active inflammatory change and recurrent polyps in June 1986, 1988, and 1990. During the 1990 endoscopic examination, the culture for H. pylori was positive. The polyps were left intact, and the patient was treated with a 2-week course of bismuth subcitrate, tetracycline, and metronidazole. In October 1990, endoscopy was again done and for the first time, the stomach appeared normal. Biopsy and culture results for H. pylori were negative. Similar results were noted during endoscopy in June 1991 and June 1992. Discussion Resolution of chronic gastritis and multiple benign, hyperplastic gastric polyps (which had persisted for more than 5 years) occurred in our patient after a single 2-week course of therapy directed against H. pylori. The patient has remained free of disease after a 2-year follow-up. This finding suggests that the H. pylori organism may have had a primary role in inciting the response in the gastric mucosa, leading to the mucosal ulcerations and hyperplastic polyps. The benign, hyperplastic gastric polyp probably represents a regenerative process in response to the localized ulcerations associated with the chronic gastritis. Treatment of patients with triple-drug therapy (including bismuth, tetracycline, and metronidazole) is as effective as cimetidine in the treatment of acute duodenal ulcer [4]. The mechanism of action of bismuth subcitrate also involves the formation of a protective layer in the ulcer base and increased mucus secretion, although the bactericidal effects against H. pylori may be more important. When H. pylori is present in a duodenal ulcer, mucus secretion is inhibited. An increase in mucus secretion associated with triple-drug therapy may reflect elimination of H. pylori in the ulcer [5]. After treatment, areas of gastric metaplasia return to normal, suggesting a healing of the underlying histologic abnormality [6]. Long-term follow-up studies have shown a decreased recurrence rate in treated patients compared with those recovering from conventional ulcer therapy [2, 7, 8]. This result supports the proposed active role of H. pylori in the pathogenesis of the histologic defect. This report documents some new and unusual findings. The presentation of benign, hyperplastic gastric polyps with blood loss sufficient to cause iron deficiency anemia is unusual. Additionally, a 7-year longitudinal study of polyp formation and the elimination of any recurrences after eradication of H. pylori have not previously been described. When multiple hyperplastic polyps of the stomach are found, testing should be done to detect H. pylori. Effective treatment directed at the eradication of H. pylori may resolve the problems of active gastritis, recurrent polyposis, and possibly anemia; multiple endoscopic procedures (which are uncomfortable) are also avoided.