Surgical Science, 2011, 2, 366-368
doi:10.4236/ss.2011.27080 Published Online September 2011 (
Copyright © 2011 SciRes. SS
A Rare Combınation of Gastric Inflammatory Fibroid
Polyp and Hiatal Hernıa
Coskun Polat, Murat Burc Yazicioglu*, Serkan Turel, Mehmet Nuri Kosar, Yuksel Arikan
Departme nt of Surgery, Afyon Kocatepe University, School of Medicine,
Afyonkarahisar, Turkey
E-mail: *
Received March 8, 2011; revised May 13, 2011; accepted August 10, 2011
Inflammatory fibroid polyp (IFP) is a rare solitary gastrointestinal lesion of unknown etiology. It generally
presents as polypoid mass in the gastric antrum. Mostly affects adults at average age of 60 years. IFP can
cause different symptoms such as abdominal pain, gastrointestinal bleeding, intestinal obstruction or
intussusception. IFP is a bening lesion and it may rarely mimic the submucosal tumor. The diagnosis can be
possible after removal of the detected lession either by laparoscopic or open approach. In the present paper,
we report a patient with gastric IFP and hiatal hernia. IFP was excised throughout the gastrotomy and
following hiatal hernia was repaired. According to our best knowledge, this may be the first case report of
gastric IFP concomitance with a hiatal hernia.
Keywords: Gastric Inflamatuary Fibroid Tumor, Vanek, Diagnosis and Treatment
1. Introduction
Inflammatory fibroid polyp is a relatively rare disorder
which is thougt to b e clin ically an d histo logically ben ig n,
and was first described as “polypoid fibroma” in 1920 by
Kojetzny [1]. It may occu r throughou t the digestiv e tr act ,
but is most often seen in the stomach (approximately
80%) and usually occured either in the antrum or
prepyloric region [2]. It is slightly more common in
women (female:male ratio 1.6:1) [3]. It can be encoun-
tered in all age group but peak incid ence is between sixth
and seventh decades [4]. IFP originates from submucosa
and grows as a solitary polypoid or sessile mass which
may macroscopically mimic gastric cancer. When it is in
the stomach, most frequently seen symptoms are
vomiting, epigastric pain and bleeding. The lesion lo-
cated in the small bowel can cause intussusception and
obstruction. The diagnosis of IFP remains difficult be-
cause of all available methods such as barium swallow or
even endoscopic with endo scop ic ultrasonog raphy (EUS )
provide only nonspesific, insufficent information. In the
case of submucosal lesions, standard biopsies are in-
sufficent in obtaining adequate tissue. So that endo-
scopic tumor excision or laparotomy is recommended. In
this paper, we aimed to report a patient with IFP and
hiatal hernia and to review the literature.
2. Case Report
A 75 year-old man was referred to our hospital with
complaints of nausea, abdominal pain and distention
which was known for three years. Endoscopic exami-
nation had been performed from the same complaints
three years ago. En doscopy revealed a hernia poch at 7th
cm below the Z line, and a 5 - 6 cm diameter of hiatal
hernia and stomach was torsionized from this bare area.
We could not perform endoscopic biopsy, because of the
severe elevation in his arterial tension. A barium swallow
was recommended, but he accepted neither barium
swallow nor treatment. In his last admission, endoscopic
examination showed a giant hiatal hernia, chronic
gastritis and a mass in the bulbus; then multiple biopsy
was obtained. On histhopathological examination, chronic
inflammation and erosion were seen. Computed tomo-
graphy (CT) revealed a giant hiatal hernia and a 2 × 7 cm
hypodense image in hernia bowel which was close to
liver at the right side (Figure 1).
In his history, he was operated for Benign Prostate
Hipertrophy and right inguinal hernia. No spesific family
history was identified. On laboratory examination, WBC
was 13,800/mm3.
We have decided to perform an exploratory lapa-
rotomy and Nissen fundoplication, because of he had a
Figure 1. A giant hiatal hernia shown by CT.
giant hiatal hernia concomita nce with a gastric tumor. At
laparotomy, a 5 × 3 cm mass was found at the antrum of
the stomach. It was excised after a gastrotomy was
performed at the region of prepyloric antrum. In the
frozen section, there were no malign cells at the base-
ment of the lesion. Histopathologic evaluation of the
specimen demonstrated a fibroblastic stroma with exten-
sive thick-walled capillary vessels, spindle cells, and an
inflammatory infiltrate with numerous eosinophils within
the submucosa (Figure 2).
3. Discussion
IFP arises from submucosa of the gastrointestinal tract. It
consists of loose connective tissue with a rich vascularite
and abundant fibrous component [5]. Usually the lesion
was sessile or polypoid with ulceration of the overlying
mucosa [6]. IFP was mainly located in the pyloric region
of the stomach, less frequent in the ileum, and only occa-
Figure 2. Radiologic view of mass in the stomach.
sionally in the colon or oesophagus. IFP is non-neoplas-
tic in nature and its cause remains unclear [6,7]. Eosino-
philic infiltration which sometimes may occur as a sub-
mucosal tumor was also related to parasitic infections
such as gastric anisakiasis [8,9].
The clinical presentation and the radiological findings
of IFP may change to the size of the lesion and location.
Small lesion is usually asymptomatic until the occur-
rence of pyloric stenosis or small bowel obstruction [5].
Although they are usually small and asymptomatic, it
can cause gastrointestinal bleeding, abdominal pain,
vomiting, weight loss, intestinal obstruction or intus-
susception. Physical examination is usually not conclu-
sive and imaginings such as upper GI series, ultrasono-
graphy or CT can help diagnosis. Final diagnosis is
generally based on endoscopy and histopathological
Histopathologically, IFP has been found to be charac-
terized by a submucosal lesion with a mixture of prolif-
eration of fibroblasts and small blood vessels, accompa-
nying a marked eosinophilic infiltration [10]. Since the
distinctive structures for diagnosis are located within the
submucosa and at the base of the mucosa, the diagnosis
may not be possible in most of these polyps by endo-
scopic biopsy specimen [2].
The etiopathogenesis of IFP remains unclear. It has
been hypothesized that several factors could damage the
gastrointestinal mucosa and expose the stroma to several
irritants (chemical, mechanical and biological), and
stimulate the formation of polyps among certain people
[11]. A polyp of this category is a specific response of
gastrointestinal stromal tissue of unknown etiology [2].
Electron microscopic study revealed that IFP represented
a reactive lesion of myofibroblastic nature [12]. Tod ay, it
has been now generally accepted that IFP is not a neo-
plasia, but a reactive process, either to an allergy or a
foreign body and has no malignant potential [13,14]. A
few recent studies also revealed a relation between IFP
and H. pylori infection but an infective ethiology has
never been reported yet [11]. In one of these reports, the
patient also had an autoimmune diseases (sarcoidosis,
rheumatoid arthritis, and ankylosing spondylitis) [15].
This finding supports the possibility of an immunological
reaction as a contributing factor.
The majority of gastrointestinal polyps can be diag-
nosed and treated by endoscopically. This may be per-
formed at a single sitting or as a staged prodecure after
biopsy. The problem with submucosal lesions is the low
probability of obtaining a definite biopsy. If the tumor is
larger than 4 cm, there may be ulceration of overlying
mucosa, making biopsy easier. Endoscopists should al-
ways suspect submucosal mesenchymal tumors of being
gastrointestinal stromal tumour, leiomyoma or leiomyo-
Copyright © 2011 SciRes. SS
Copyright © 2011 SciRes. SS
sarcoma especially when tumor macroscopically mimics
a malignant lesion. Biopsy specimens using standart for-
ceps may not be adequate for histological diagnosis
when tumor is covered with normal mucosa. Then endo-
scopic excision/polipectomy preceded with endoscopic
ultrasonography should be performed as the best diagnos-
tic method [6]. There were some reports concerning the
curative role of endoscopic removal of IFP [17]. Small
IFP (generally 1 cm or less in size) can be safely
removed by endoscopy, but there is a possibility of local
recurrence after operation [16]. But with increasing ex-
perience in minimal access surgery, most of these tumors
are managed using endoscopic, laparoscopic, or com-
bined endoscopic and laparoscopic approache. An ex-
ception is a large submucosal lesion which can cause the
disruption of the tumor. In these circumstances, the open
procedure is a viable option. In our case, we also pre-
ferred open procedure because of the the mass was so
huge to be removed by endoscopically and we had no
sufficient experience about the laparoscopic gastric sur-
As a result, we consider that the treatment of IFP is
surgical resection and every surgeon should have suffi-
cient knowledge and experience about its diagnosis and
surgical treatment.
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