Pedunculated Tumors of the Stomach Prolapsing through the Pylorus

Though not a common roentgenologic finding, pedunculated tumors of the stomach cannot be considered rare. Many have been demonstrated when prolapsed through the pylorus into the duodenum. Few cases however, have been described, in which the tumor was shown roentgenologically to oscillate on its pedicle between the stomach and the duodenum, as in our case. Rigler recorded a case in which the polyp was first discovered in the duodenum. On subsequent examination it was found proximal to the pylorus and was manipulated across the pyloroduodenal junction into the duodenum. Similar cases are recorded by Schons and by Lönnerblad. The incidence of pedunculated tumors is hard to estimate accurately. Eliason, Pendergrass, and Wright reviewed the literature on benign gastric tumors up to 1926. Of the 611 tumors in their collected series, 48 or 7.5 per cent were pedunculated. Two of these had been shown by Moore to have prolapsed into the duodenum. Eliason and his associates added 50 cases of benign gastric tumor, of which 10 were pedunculated and 5 had prolapsed through the pylorus. Pendergrass in 1930 recorded several more examples of prolapsed tumor, and McLaughlin and Conlin described still another case. If we accept the incidence of benign gastric tumors as 1.3 per cent (Eusterman and Senty) to 4.5 per cent (Minnes and Geschiekter) of all gastric neoplasms, and consider that less than a tenth of these are capable of prolapse, we may place the incidence of prolapsing tumors at a fraction of 1 per cent of the total number of new growths in the stomach. Etiology The etiology of pedunculated gastric tumors, like that of all new growths, is uncertain. Eliason and Wright suggest that the first step is gastric irritation, giving rise to a gastritis causing local hypertrophy of the gastric mucosa. This hypertrophy is further increased by peristalsis and the passage of food over the surface. As this process continues, the tissues become stretched and a pedicle forms. When this stalk becomes sufficiently long, it permits prolapse of the polyp into the pylorus. It is believed that alcohol is responsible for the formation in most cases. Pathology Pedunculated tumors are of four chief types: (1) solitary benign tumor, (2) pedunculated carcinoma, (3) a part of a multiple polyposis, (4) prolapsed mucosa. The benign tumor may be of epithelial, mesothelial, endothelial, or of mixed origin. It may be papilloma, adenoma, myoma, myxoma, polyp, cyst, fibroma, or lipoma. The size varies from a few millimeters to 15 or more cm. in diameter. The larger tumors may weigh several pounds. The average length of the pedicle is 2 cm. The malignant tumors are of two chief varieties. The more common form is a benign tumor which has undergone malignant change. A fungating carcinoma may, however, prolapse into the duodenum. Cases have been reported where both a carcinoma and a benign polyp were present.