and on

(Glt, 1989,30, 1624- 1629

Case report

Giant fibrovascular polyp of the oesophagus: report of a case and effects on oesophageal function

R PENAGINI, T RANZI, P VELIO, P ZANNINI, G NEGRI, G PEZZUOLI,

AND P A BIANCHI

Fironmthe Cattedra di

Patologia

Medica Ill, Istituto diScienze Mediche andIstituto di Clinica Chirlurgica I,

Unire'rsity

(/Milan, Italy

SUMNINIARi'

A

40 year old

man

with dysphagia and

a

giant fibrovascular polyp of the oesophagus is reported. The patient

was

followed for

two

years before removal of the polyp. During this period the

tumour

markedly increased in size and the oesophagus reached

a

maximum diameter of 5.9

cm.

In presence of the polyp the body of the oesophagus had

no

pressure activity after swallows and

a

22 hour intraoesophageal pH record showed pH>7 for 31.4% of the time and

never

pH<4. After excision of the

tumour

the oesophagus regained normal size and peristalsis. Intraoesophageal pH>7 and <4

were

recorded for 1.6% and 161% of the time respectively. Dysmotility

was

probably

a

contributing factor

to

the genesis of dysphagia induced by the giant fibrovascular polyp. Prolonged alkalinisation of intraoesophageal pH conceivably reflected altered oesophageal clearing of alkaline salivary and/or oesophageal secretions.

Benign tumoursof the oesophagusare uncommon.'--"

They are mainly leiomyomas, but fibrovascular polyps, although much rarer, were known to physicians even before the use of radiology and endoscopy` astheyaresometimesregurgitated into the mouth. Not infrequently fibrovascular polyps posediagnosticproblems especiallywhen theyattain giant proportions, being confused most commonly with achalasia and non-pedunculated intramural tumours."'-'' Fibrovascular polyps have been des- cribed with different names such as pedunculated fibromas, fibrolipomas, lipomas, myxofibromasand hamartomatous polyps.'1 "''-' About 60 have been

reported"'

todate, whichdeveloped almost exclus- ively in the cervical oesophagus at the level of the cricoid cartilage. It iscommonly thought'' that the symptoms induced by these polyps are caused by mechanical obstruction, however, there are no data regarding their possible influence on oesophageal motor

fLliction.

We report the case of a man

s\flrc.s o rrespondelnciic:D)r RIktn.,llii (Cattdedra Pat(11oI1 Melticai111, 'ad(ri*,,m lli. FStorai 3..'(}10122MIL,o.li Itah.

\cce'ptedfoi publicatioin14NMirch1')X.

with a giant fibrovascular polyp of the oesophagus causing severe dysphagia, in whom oesophageal motility and 22 hourintraoesophageal pH monitoring were performed before and four months after excision ofthe tumour.

Case report

A 40yearold man was referred to ouroutpatients' clinicinJuly 1986 with a 10 day history of dysphagia, odynophagiaand a sensationofalumpinthe throat.

At that time the patient was able to follow a semiliquid diet only.

Hispastmedical history included anxietyand chest

oppression,

the latter being considered a psycho- somaticsymptom. A barium meal done in 1973 for postprandial heartburn was apparently normal (Fig.

Ia).

Physical examination and routine blood tests were unremarkable. A barium swallow was done immediately and showed (Fig. lb) a dilated oeso- phagus (maximum diameter 4-5 cm) containing a large fillingdefectextendingfrom the neck to a few cm above the cardia. At upper gastrointestinal 1624

Fibro

vascularp

k

olxvp

atndoesophagealfunction

Fig.1 Bariumswvallows:(a)in1973; (b)ini1986,atpresentation;(c) in1988,beforeexcisionofthepolyp;(c)in1988,,foiir.

monthsafterexcisionofthepoip. Notetheprogressive dilataitionoftheoesophagusbeforeexcisionof t/epolipa(nd1tretlurnto anormal sizefouir months after excision.

endoscopy a mass was identified which started immediately below theupperoesophagealsphincter, extendedup to7-8cmfrom thecardia, wascovered with normal mucosa, and appeared progressively largerasthescopemoveddistally. Themucosaof the distal 3 cm of the oesophagus showed erosive oesophagitis. The patient refusedanyfurther investi- gations or surgery. His symptoms fluctuated, but worsenedprogressively and he lost 10 kg in

weighlt

up toMay 1988when heagreedtobefurtherinvestigated and eventually to have his mass removed. At this timehisbloodtestsshowedanESRof108, Hb 11-3

g/dl,

WBC 11300/mm3, platelets

41000()/mmM

and raised u2 globulins. A repeated barium swallow showed

(Fig.

Ic) a substantial growth of the mass (maximum diameter of theoesophagus

5*9 cm).

An uppergastrointestinal endoscopy showed themassto extend up to 3 cm from the cardia. To clarify the natureof the tumour acomputed tomography (CT) scanofthe neck and chest(Fig. 2)wasthenperformed which showed a mass of homogeneous density, comparable to density of the lax connective tissue, which did not infiltrate the oesophageal wall nor compressed the trachea. A magnetic resonance imaging(MRI) scan was also done which did not add

anyinformationtothe computedtomography. Aftcr barium swallow, endoscopy, computed tomography and magnetic resonance imaging scans, it remained

Fig.2 C(ompterisedlomogratnof lhe c/est sho wingtinl

app)/)arentlS'

inotnural,nts swit/lintheoesphaulls.

1625

16Penagini, Ranl-i, Veijo, Zannltini, Negri, Pecciioli,t(/11

B3ianchli

1.i. ....i (,1ot% %|( i.I) ^...

...u_l¹

~~~

¹

1

^..,,K

unckear whicther the. miss w_1sintraluminal or intra- mural. On Jine 16, 1988 the patien.t ^Linerwent

surgery. Aright thoracotomy andla4cmi longitudinal oesopha~gotomy above the aortic arch were clone.

A big, pedulnculated muitltilobuila.ted. polyp, attached to the cervical oesophaguis just below the upper

oesopha~geatl sphlincter, was found and excised. The

gross specimein (Fig. 3) was 14.5 cmn long, had a maximum diamneter of' 7 cmi arid a 2 cmn stalk. Its appear.ancewas sinoothi and It had ulceration on

itssurface. Histopathological analysisshowed ittobe

comiposed of fibrousconniective tissuec withi myxoid

areas,a few fatcells,clhronilcinftlammiatory^infiltrate

andsmnall conigested vessels, aind appearancetypical

ofafibrovascularpolyp.`

The patient niadean tLlneverltftlI recoveryandwas, seen againin ^November 1988when lereportedthat

hiewacscom-pletely^free of'dysphagia,. Hisweightand

roLutlile bloodtestshadretuirnedtonornmal. Anl uipper evastrointestinialendoscopy,showednoreminantof the

polyp and a longitudinal scar at the site of the

previouis oeSophaigotomviy. E-rosive oesophagitis was

grossly _nchanged.

I VA I.UATIION O;01'SOP1AG Al. FU NCIAI)N

Oesophageal manometry and 22 hintraoesophageal pH monitoring were performed before excision of the mass (May. 1988) and four months after (November, 1988). Oesophageal imacnitomiietrv was

donc using a low compliance

pneumilohydraulic

infusion system(Sensormedics, Italy)at aflow rate of 0(5 mI/min and four external pressure transducers (Sensormedics 223651) connected to a polygraphi (Sensormedics, model R711),

permittinig

a response of>200 mmHg/sec.''Lowerand upper

oesophligCal

sphincter activity were investigated using the slow pull through technique. The oesophageal bodywas assessedintwostages: at3, 8, 13, 18 cm and at8, 13, 18, 23 cm above the lower oesophageal sphincter.

The most proximal port was placed in the cervical oesophaigus just below the upper oesophageal sphincter. The average of data from all ports after wet (5 ml) swallowswas used tocailculcite amplitude and duration of the peristaltic wave. Twenty two hour intraoesophagealpH monitoringwclsperformed following a protocol already reported in detail.5' Briefly, the test was done during hospital admission with anambulatory system(Synectics, Sweden)using an antimony pH electrode placed 5 cm above the manometrically determined lower oesophageal sphincter. The electrode was thus positionied at a level where the lumen was filled with the mass. The patient had meals at0800, 1200,and 1800 h and spCent 13 hours in upright and niic hours in recumbent position. The tracinlg was analysed witth respect to percentage of time at pH<4 as a measutre of gastro- oesophageal rcfluxanid with respect to percentage of time at pH>7 as an index of alkalinisation of'

intraoesophageal

cnvironment. We have recently slhowin that intraoesophageal alkalinisation is not caused by reflux and it is presumably determinedby thepHofswallowedfluids.'

Preoperativeoesophageal manometryshowed the loweroesophageal sphinctertohave abasal tone of 6 mmHg and apparcit complete relaxations after swallows. The intraoesophageal baseline equalled the intragastric one The oesophageal body did not show any pressure activity after 20 swallows (Fig. 4a). Thepatient was noted to belch after each wet swallow. Monitoring pressures in the hypo- pharynx and upperoesophagealsphincterduringfive additional wet swallows showed that the sphiincter had a basal tone of 45 mmHg and presented two complete relaxations after each swallow, separated by3-0-3.5 sec one from the other. Thefirstrelaxation occurred normally just before the hypopharyngeal contraction and allowed the water to beswallowed.

The second one allowed a belch to occur and was unaccompanied by pharyngeal contraction. Post- operative oesophageal manometry showed simillar 1626

Fibr'o1as'cular polYp

tiitld

oesopliagealitnction1

W.S. W.S. W.S.

.

W.S

18cm - 23cmm -t. W-

13cm _ ^18cm _

W.S. W.S.

w .. w..

18cm'~-"'/

13cm-

W.S. W.S.

L_ ^--

j25mmHg

10 sec 23cm

18cm ___

8cm - 13cm 88cm

'vvAcm

13cm

3cm _ 8cm -v._- 3cm 8cm

Fig.4 Oesophagealmanometrytracitigs: (a)beforeexcisIonof

thepJolp:

*oote cootplete ab1)senteeofpressuter(cctivitv; (b)fourlll

mtioiths after excision ofthepolyp. Theport placed 23 cotZ above tite lotweroesopht(lgealsp)htinlcter is wt'itlhint the cervical oesophagtlsju.stbelotv titelipperoesopliagealsphlincter. IVS=-tet.stvallotv.

lower oesophageal sphincter function (8 mmnHg) and

an intraoesophageal baseline 6 mmHg less than the intragastric one. In the body, peristalsis was seen

after 20 swallows with a median amplitude of 36 mmHg (range: 31-44 mmHg), a median duration of three seconds (range: 2-4-3.2 sec) and a median volocity of 2 4 cm/sec (range: 2-2-3.0 cm/sec) (Fig. 4b). The port situated 18 cm above the lower oesophageal sphincter, correspondingtotheareaof the oeseophagotomy, recorded very weak contrac- tions (<10 mmHg) only. The upper oesophageal sphincter showeda basal toneof 35mmHg andone

complete relaxation after each swallow.

Preoperative 22 h intraoesophageal pHmonitoring showed no acidification of intraoesophageal pH, which in turn remained alkaline for 31.4% of total time (60.3% in recumbentposition). Post-operative pH monitoring revealed prolonged acid reflux, especiallyatnight. Percentageoftotal time atpH<4

was 16.1 (28X8 in recumbent position). In contrast, alkalinepHwasrecorded foronly 16% oftotal time

(1.7% inrecumbentposition).

Discussion

Toour knowledge, about 60 cases'-'- ofgiant fibro-

vascularpolyp of the oesophagus have been reported inthe literature. Wedescribeanadditionalpatientin

whom the effects of the ^{mass on}oesphageal motility and pH were investigated. At preoperative mano-

metryno pressure activity whlatsoeverwasdetected

in the oesophagecal body. Although we could not

identifya reasonfor this alteration, threehypothleses, not mutually exclusive, ^may be proposed: first, a

directmechanical effectofthemasswhichmayhave absorbed the force generated by the oesophagecal wall; second, a reflex inhibitioni of oesophageal motility triggered by oesophageal distentioti similar

to previoLis findings in experimental conditionis;5';

and third, the effect of the increase in cylindrical bowel radius which, according to Young and Laplace's law, isinversely proportionial tothe intra- luminal pressure generated by muscle contractionr.

Whatever the mechanism was, the alteration of

motor function inpresence ofourpolypwasrevers-

ible. Four months after excision of the mass the oesophagus had regained its normal size and peristal- sis, although the amplitude of thepressurewaveswas at the lower limit of the normal range." Intra- luminalpressureswerestillalmost absentatthe level of theoesophagotomy only, whichwasprobably the result of thc operation itsclf. Thc mcchanism by whichabenign tumour like thepresentone induces dysmotilityseemstobedifferent from thatoperating

in malignant

oesophageal

tumours, accordigl to a

recent report.-' In those cases dysmotility remained unchanged after laser ablation of the tumour and it wasprobably caused by intramural infiltration. The

response ofthe upperoesophageal sphincterto wet

swallows during the preoperative oesophageal

C-

a, OC.

-c 7:

0 '0Q.

.0

_l a __j

1627

A A

1

1628 Penagini, Ranzi, 1Velio, Zannini, Negri,

Pezzu,oli,

andBianchi manometry was interesting. Conceivably, stasis of

the swallowed water in the cervical oesophagus induced sudden distention of the oesophageal wall, which in turn triggered an upper oesophageal sphincter relaxation7 and

consequently

an oeso- phagopharyngealgas refluxaftereach swallow.

Interpretation of pH monitoring data before operation should take into account that the pH electrodewasplacedat a levelwherethe lumen was filled withthe mass. Thus from our pH dataitseems that on the one hand the polyp prevented gastric retiluxateuptheoesophageal lumenand onthe other it grossly altered oesophageal clearing, determining stasisofalkaline saliva and/oroesophageal mucus.

Persistence of oesophagitis after excision of the tumour, prolonged reflux recorded postoperatively and heartburn in the medical

history

all suggest that erosive oesophagitis was unrelated to the tumliour, butwasinsteadcausedbycoexistinggastro- oesophageal reflux disease.

The absence of the polyp in the thoracic oeso- phagusatthe barium swallow in 1973 and substantial incrcasc inthesizCbetween 1986and 1988agree with a

previous

report which

documenited

a visible polyp enlargemeintafter

oley

year of ollow up. l

It is interesting that a raised ESR, which was documentedinourcaseandin previous ones,"' may notnecessarilysuggestmalignant degeneration of the polyp, but could simply be caused by inflammation within the tumour.

Finally, misdiagnosis of the pedunculated nature of the tumour has led to more complicated and hazardous surgical procedures than cervical approach andoesophagotomyon afewoccasions' -" (andour case) and

evenI

the additional use of computed tomography and magnetic resonance imaging scans haveprovedunhelpful' (and our case) in this respect.

It

scemIls

clearto us after

extenisive

revisions ofthe

literaiture

on

oesophalgeall

mass

lesioins,

however, thatamiasswith the density oflax

connective

tissue at CT scan andfillingmostof the oesophagus

cannot

be

anythingbLut

a giant fibrovascular polyp. Thus, as

fibrovaSculalr

polypsarenearlyalways attached to the cervical

oesophagus, oesophalgotomy by

the cervical route is the

operation

of choice even if the pedun- culatedn ItUreof the

mass

is

not

apparent.

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doi: 10.1136/gut.30.11.1624

1989 30: 1624-1629 Gut

R Penagini, T Ranzi, P Velio, et al.

effects on oesophageal function.

oesophagus: report of a case and Giant fibrovascular polyp of the

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