Case Reports 231
Table 1. Eosinophil counts per microliter
1st hospital day Later during hospital stay
473 (8th day)
742.5 (5th day)
1,113 (4th day)
The eosinophil counts were not enhanced on the 1st day, but
Department of Gastroenterological Surgery
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Sendai 980-8574 (Japan)
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Inflammatory Fibroid Polyp or Vanek’s Tumour
D. Paikos a , J. Moschos a, b , D. Tzilves a , A. Koulaouzidis c ,
G. Kouklakis b , F. Patakiouta a , K. Kontodimou a , A. Tarpagos a ,
I. Katsos a
a Theageneio Hospital, Thessaloniki, bMedical School,
Democritus University of Thrace, Alexandropolis, Greece;
cLlandudno General Hospital, North West Wales, UK
Gastric inflammatory fibroid polyp ? Vanek’s tumour ? Gastric
outlet obstruction ? Projectile vomiting
We report a case of a 65-year-old woman who presented with re-
current episodes of severe, postprandial abdominal pain followed by
projectile vomiting. Gastroscopy revealed a large polyp in the prepy-
loric region. During peristalsis, the polyp was repeatedly ‘passing’
through the pylorus into the duodenal bulb, hence obstructing the
lumen. The polyp was eventually removed in a piecemeal fashion.
Histopathologic examination revealed an inflammatory fibroid pol-
yp (known also as Vanek’s tumour). A brief review on inflammatory
fibroid polyps follows.
Copyright © 2007 S. Karger AG, Basel
Inflammatory fibroid polyp (also known as Vanek’s tumour)
is an uncommon, non-neoplastic proliferating lesion which can
develop in various parts of the gastro-intestinal tract but most
commonly in the gastric antrum and the ileum. The majorities of
Vanek’s lesions are asymptomatic and discovered as incidental
findings during endoscopy performed for unrelated reasons.
When symptomatic, Vanek’s tumours are usually associated with
abdominal pain, weight loss, bleeding, dyspeptic symptoms, iron
deficiency anaemia and intussusception. Their size determines
whether they are symptomatic or not. Macroscopically, inflam-
matory fibroid polyps appear as sessile polypoid lesions, usually
less than 4 cm in diameter. Histologically, they are mainly con-
fined in the submucosa, characterized by vascular and fibroblas-
tic proliferation together with an inflammatory response (usu-
ally dominated by eosinophils). Endoscopic excision is the treat-
ment of choice as the prognosis is overall benign.
A 65-year-old woman was admitted with recurrent episodes
of postprandial, projectile vomiting and severe epigastric pain
over a period of a few months. Her clinical examination was un-
remarkable and routine blood tests were within normal limits.
Gastroscopy revealed a large (3 ! 5 cm), polypoid lesion in the
prepyloric region. Figure 1 shows the lesion protruding through
the pylorus into the duodenal bulb causing gastric outlet obstruc-
188.8.131.52 - 9/21/2014 12:55:07 PM
tion. During the procedure, the polyp was removed in a piecemeal
fashion. Histopathologic examination of the polyp revealed a fi-
broblastic stroma, with extensive thick-walled capillary vessels,
spindle cells and an inflammatory infiltration (mostly eosino-
phils) within the submucosa ( fig. 2 ). These findings are consid-
ered pathognomonic for the diagnosis of inflammatory fibroid
polyp (Vanek’s tumour). Helicobacter pylori was detected on the
gastric surface. The patient was commenced on eradication ther-
apy for 10 days. Six months later, the patient was asymptomatic
and had a normal gastroscopy.
Inflammatory fibroid polyp is an uncommon non-neoplastic,
proliferating lesion of the gastro-intestinal tract, initially de-
scribed as eosinophilic submucosal granuloma by Vanek in 1949
 . Vanek suggested that the tumours have an allergic aetiology
due to the presence of eosinophils. Vanek’s tumours are most
commonly found in the stomach (gastric antrum) and the ileum,
but can occur throughout the gastro-intestinal tract of adults and
children (wide age range: 2–90 years). The reported series indi-
cate a slight male predominance  . They are usually asymptom-
atic and likely to be incidental findings during endoscopies per-
formed for unrelated reasons. When symptomatic, they present
with abdominal pain, weight loss, ulcer-like symptoms, overt gas-
tro-intestinal bleeding or iron deficiency anaemia  and intus-
susception [4–6] . Their size is the main determiner of their clini-
cal presentation  . There are no valid data regarding their
growth and no clear evidence whether their growth stops after
reaching a certain size or whether they continue to enlarge. Once
resected, they neither recur nor do additional lesions develop in
the rest of the stomach. Microscopically, Vanek’s tumours can be
mistaken for a variety of lesions, from granulation tissue to high-
grade sarcoma. In the differential diagnosis, it is important to
include eosinophilic gastro-enteritis, gastro-intestinal stromal
tumour, inflammatory pseudo-tumour, haemangioendothelio-
ma and haemangiopericytoma  . Endoscopically, Vanek’s tu-
mours are sessile, polypoid lesions usually less than 4 cm in di-
ameter (our case had a big polypoid lesion with a diameter of
1 5 cm). They appear to arise from the submucosa and may show
surface ulceration. Microscopically, they are mainly composed of
mononuclear, spindle cells with an eosinophilic cytoplasm often
arranged in a perivascular pattern (onion skin appearance). The
characteristic spindle-shaped cells are usually located in the deep
submucosal layer and therefore, examination of endoscopic bi-
opsy samples seldom reveals the characteristic findings. Overall,
the lesions tend to be vascular and inflammatory cells (mainly
eosinophils and lymphocytes) are invariably present  . In some
polyps, eosinophils are particularly abundant, but it is now clear
that this feature is not associated with peripheral blood eosino-
philia and certainly does not reflect an allergic pathogenesis.
There is no evidence to support a possible association between
inflammatory fibroid polyps and eosinophilic enteritis. Immu-
nohistochemical analysis demonstrates diffuse positivity for vi-
mentin and variable reactivity for actin, CD34, CD68, desmin,
CD117, and S100. Factor VIII and cytokeratin are usually negative
 . Endosonographically, an inflammatory fibroid polyp is pre-
dominantly a hypo-echoic, homogenous mass within the second
and third sonographic layer.
Its aetiology is unknown. It is believed to be a poorly con-
trolled inflammatory repair response  . The pathogenesis of in-
flammatory fibroid polyps remains largely unknown. Prominent
H. pylori infection was demonstrated in some cases of gastric
Vanek’s tumour and remarkable morphological changes were ob-
served after its eradication. In a case described by Matsuhashi et
al.  , a 2-cm elevated lesion at the prepyloric region regressed
and eventually disappeared in as little as 3 months after eradica-
Fig. 1. Vanek’s tumour in the prepyloric region.
Fig. 2. Microscopically, whirls of spindle cells around blood ves-
sels and heavy inflammatory infiltrate rich in eosinophils.
184.108.40.206 - 9/21/2014 12:55:07 PM
Case Reports233 Download full-text
tion. The reason why chronic H. pylori -associated inflammation
leads to hyperplastic polyps in some patients and to inflamma-
tory fibroid polyps in others remains to be elucidated. The lesions
can also appear in the oesophagus, the small intestine and the
colon. In such cases, a causative role of H. pylori is difficult to as-
certain. Endoscopic removal is recommended as a safe and effi-
cient treatment. Vanek’s tumours do not recur after surgical re-
section. In our patient, the endoscopic polypectomy of the lesion
was followed by H. pylori eradication therapy with excellent re-
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Papadimitriou 10, Kalamaria
Tel. +30 231 042 1152, Fax +44 192 566 2402
6 Chongsrisawat V, Yimyeam P, Widesdopas N, et al: Unusual manifesta-
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