MKSAP: 54-year-old man with dysphagia

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 54-year-old man is evaluated for a 4-month history of intermittent, nonprogressive solid-food dysphagia. He has a long-standing history of heartburn that has been well controlled with once-daily proton-pump inhibitor (PPI) therapy for the past 5 years. Results of a screening colonoscopy 4 years ago were normal. There is no family history of colorectal cancer.

Physical examination findings are unremarkable.

Upper endoscopy reveals a 3-cm hiatal hernia, an esophageal (Schatzki) ring, and approximately six polyps smaller than 4 mm in the fundus and upper body of the stomach. The duodenum is normal. The esophageal ring is dilated, and biopsy of random gastric polyps confirms fundic gland polyps without dysplasia.

Which of the following is the most appropriate next step in management?

A. Perform APC gene testing
B. Perform excision of all fundic gland polyps
C. Repeat colonoscopy
D. Stop PPI therapy
E. Reassurance

MKSAP Answer and Critique

The correct answer is E. Reassurance.

The most appropriate next step in management is reassurance. Fundic gland polyps (FGPs) are among the most commonly found gastric polyps and are reported to be diagnosed in up to 5% of patients undergoing upper endoscopy. Sporadic FGPs are usually 1 to 5 mm in size and fewer than 10 in number. Sporadic FGPs have been associated with proton pump inhibitor (PPI) use; the exact mechanism of this association is not known. Sporadic FGPs do not have malignant potential; therefore, this patient does not require PPI cessation, excision of the remaining polyps, or surveillance.

It is important to distinguish sporadic FGPs from those related to a hereditary colon cancer syndrome. Familial adenomatous polyposis (FAP) is an autosomal dominant hereditary colon cancer syndrome caused by an APC gene mutation. It is associated with the near-universal presence of gastric fundic gland polyposis, duodenal adenomas, and a personal or family history of early-onset colonic adenomas or colorectal cancer. FAP-related FGPs frequently harbor dysplasia. APC gene testing is not warranted because this patient does not have dysplastic FGPs, a personal history of duodenal or colonic adenomas, or a family history of colorectal cancer.

Colonoscopy is recommended in patients with dysplastic FGPs or in those younger than 40 years of age with fundic gland polyposis; neither of these characteristics is present in this patient, so colonoscopy is not necessary at this time.

This patient’s esophageal ring is an acid-related complication of gastroesophageal reflux disease that requires esophageal dilation and ongoing use of a PPI. Therefore, stopping PPI therapy is not appropriate at this time.

Key Point

  • Sporadic fundic gland polyps have been associated with proton pump inhibitor use and do not require excision or surveillance.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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