Hamartomatous gastric polyp.. A case report of atypical presentationAbstract:Most gastric polyps have an asymptomatic presentation and are an incidental finding on upper endoscopy. Symptomatic presentations can range from an ulcerated polyp leading to anemia and bleeding up to complete gastric outlet obstruction. We present a case presented to us by jaundice, vomiting, And upper abdominal pain for 2 weeks. ultrasound shows a picture of acute pancreatitis due to obstructive jaundice . In upper endoscopy, initially we find a large pedunculated gastric polyp passing through pyloric ring up to 2nd part of duodenum causing a compression on duodenal papilla It was withdrawn back to stomach after grasping with a snare. Then removed by piecemeal technique after injection of the pedicle with diluted adrenaline. Bleeding after snaring the pedicle was secured with injection of diluted adrenaline and a insertion of a haemoclip. with complete resolution of all symptoms Introduction:Gastric polyps are found in approximately 1%–6.35% of endoscopies (1). Most of these cases are asymptomatic; However large polyps can be presented by bleeding, anemia, or obstructive symptoms(2). Gastric hamartomatous polyps are uncommon and comprise about 1% of all the stomach polyps. They can be presented solitary or as a part of a clinical syndrome(3). The syndromes commonly associated with gastric hamartomatous polyps are Peutz–Jeghers syndrome (PJS), juvenile polyposis. solitary polyps are usually benign – Except for inverted hamartomatous polyps (GIHPs), which have a 20% of malignant transformation – while the symdromatic hamartomatous polyps has a higher malignancy risk. which increases with age (range, 1 to 33%) between 30 and 60 years(4).Gastric polyps may intussusept to duodenum causing gastric outlet obstruction. If the prolapsed polyp contains a functional antral mucosa over it, that mucosa may keep secreting gastrin due to being placed in the alkaline media of duodenum. In turn this hypergastrinemia may lead to erosion of the prolapsed polyp and blood loss(5).Diagnosis is often done by endoscopy, First case treated by endoscopic treatment modalities was at 1973(6).Management of gastric polyps depends on its type; In hyperplastic polyps conservative medical management and endoscopic surveillance of smaller polyps is preferred while polypectomy is indicated in large polyps (more than 0.5 cm) for risk of malignant transformation(7). Case presentation: A 24 years old man was admitted to hospital due to severe persistent vomiting, Fatigue, And upper abdominal pain which was radiated to the back for 2 weeks. This condition was followed by yellowish discolouration of sclera associated with dark color urine and low grade fever which has no specific pattern. His hemoglobin was 12 g/dL, Total Leucocytic Count: 19000 x109/L with marked neutrophilia, Platelets: 340 x109/L.Liver function tests revealed elevated aminotransferases; ALT 168 U/L, AST 137 U/L. And hyperbilirubenemia ; Total bilirubin 9µmol/L, and direct bilirubin was 7 µmol/L.Other investigations revealed: Amylase 1300 U/L, Lipase 650 U/L.Abdominal ultrasound revealed bulky pancreas, dilated Pancreatic Duct , dilated Common bile duct and Intra hepatic biliary radicle dilatation. . All of the forementioned data indicated that the patient was suffering from obstructive jaundice complicated by acute pancreatitis.Patient was referred for endoscopic evaluation. In upper endoscopy, initially we saw pyloric canal partially obstructed by a smooth surfaced pili-like structure. When passed to bulb of duodenum we observed a large pedunculated polyp 12×8 cm in size. This polyp was originated from stomach passing down to the 2nd part of duodenum.It was withdrawn back to stomach after grasping with snare (Figure 1).The biopsies taken were reported as hamartoumatous gastric polyp.It was removed using piecemeal technique after injection of the pedicle with diluted adrenaline. Bleeding after snaring the pedicle was secured with injection of diluted adrenaline and insertion of a haemoclip (Figure 2).The patient condition was improved. stayed NPO till resolution of attack of acute pancreatitis. Now, the patient is quite well and has no signs of obstruction, freely consumes a normal diet.Figure 1 : Lagre gastric polyp after pulling inside stomachFigure 2: Extraction of polyp and hemoclip insertion Discussion:In literature there is no recorded cases of such a complication of a gastric polyp; Most recorded cases of giant gastric polyps developed a picture of intermittent gastric obstruction. Meta-analysis was done at 2010 for giant gastric polyp complications, About 40 cases was reviewed and shows an old age, female predominance(8), most of these polyps are Hyperplastic (90% of cases) ; However the recorded cases of solitary hamartomatous polyps are more prevalent in younger age (Median age 43.5) with female predominate also(9).Hamartomatous polyps are composed not only of epithelial elements, but also of bundles of smooth muscle cells. The essential feature of these polyps is the proliferation of muscularis mucosa(10).Endoscopic management is preferred for large polyps, large prolapsed polyps can be dragged into stomach for easing the polypectomy procedure, instead of performing it in bulbus, which is a narrower space than stomach(11). Multiple endoscopic techniques are used for polypectomy of hamartomatous polyps; Endoscopic mucosal resection (EMR) are preferred for sessile polyps however in pedunculated polyps electrocautery snare polypectomy is done with usage of hypertonic saline epinephrine injection, endoloops, Band ligation, and endoscopic hemoclips for control of bleeding. In our case we used a combined method of bleeding control (adrenaline, hemoclip) for high risk of bleeding with successful control of bleeding(12).Larger sessile polyps have a greater propensity to bleed because of larger feeding vessels. Endoscopic ultrasound (EUS) would theoretically minimize the risk of bleed by visualizing the blood vessels at the base of the gastric polyp. Surgical interference was done only in complicated cases(13). Conclusion:Hamartomatous polyps in the stomach are rare condition with multiple clinical, histologic , and endoscopic features. Large polyps has a high risk of malignancy for which endoscopic resection is preferred, screening other family members is mandatory in syndromic hamaromatous polyposis.