Haematemesis in infancy is an uncommon entity. Septicemia, coagulopathy, necrotising enterocolitis, mallory weiss tear are few causes which predominate. Haematemesis due to gastroduodenal polyp is a very rare aetiology to find in infants. Among the polyps hamartomatous polyp and hyperplastic polyp might be encountered in infancy [1]. Here we describe an infant who presented with hematemesis and a gastric antral hyperplastic polyp was found to be the cause of the haematemesis which is a rare diagnosis.

A 5 month old female baby was admitted from emergency with history of 3 bouts of large vomit of blood for one day with one episode of melena. History revealed that the child was born of nonconsanguineous parents without any significant family history of any illness. She was born by normal delivery and was thriving. She had occasional vomiting which was regarded as GERD by her attending paediatrician. Her vomitus used to be milk and mucoid fluids without any blood or bile. Examination revealed a normally grown baby with weight of 5.5 kg. She looked pale. Abdominal examination was normal without any mass or visible peristalsis. Investigations revealed low Haemoglobin of 6.5 gm with normal total leucocytes and platelet count. Her Coagulation profile was normal. Blood gas showed normal pH and electrolytes. She was kept nil by mouth and was started on intravenous fluids and intravenous proton pump inhibitor, Omeprazole. An ultrasound of abdomen with doppler was done to exclude any duplication cyst or major vascular anomaly. Ultrasound revealed an echogenic mass at pylorus. She was transfused with 90 ml of packed red cells and an endoscopy was arranged after the transfusion was over.

On endoscopy esophagus was normal. After entering stomach there was blood in the lumen. As proceeded distally a large polypoid mass was noted with grooved, ulcerated and irregular surface (Figure 1A and 1B). It was situated about 2 cm proximal to antrum and pylorus was crossed without any resistance. 1st and 2nd part of duodenum was normal.

Figure 1: A and B) Endoscopic appearance of Gastric Polyp.

Initially an endoscopic polypectomy was planned but in view of a wide stalk in a 5 month old baby a decision of laparoscopic polypectomy was taken. On laparoscopy a wide stalked antral polyp was found which was removed. Histopathology showed the features of hyperplastic polyp. The infant recovered very well post operatively and started feeding from breast from 2nd day and was discharged on 3rd day.

Gastric polyp in infancy is an uncommon entity. The prevalence of gastric polyps in the pediatric population is low compared with that in adults (0.7% vs. 6.35%) [1,2].

Commonest pathological varieties are hyperplastic variety and are mostly asymptomatic when very small [3]. Present infant also had hyperplastic polyp in histopathology.

The pathogenesis of sporadic gastric polyps in adults and children still remains uncertain. In adults with sporadic fundic gland polyps (FGPs) mutations of the ß-catenin gene affecting the APC/ß-catenin pathway occurred and this may be involved in the pathogenesis of sporadic fundic gland polyps [4]. In pediatric population cases are limited but in future genetic sequencing of all such cases will be needed to delineate the genetic background (Figures 2 and 3).

Figure 2: Histopathology of polyp showing hyperplastic variant.

Figure 3: Macroscopic appearance of the polyp after resection.

Few cases of Gastric polyp mimicking hypertropic pyloric stenosis in infancy have been reported in literature [5]. In infancy haematemesis as a presentation of polyp is rarer; so far only one case was reported whose sole presentation was haematemesis [6]. Present case has a significant hematemesis to drop her haemoglobin to 6.5 gm.

Earlier imaging with USG or contrast imaging used to be the mainstay in diagnosis. Ultrasonic appearance of a hyperplastic gastric polyp has been described as an echogenic polypoid mass arising from distal antral mucosa [7]. Presently availability of paediatric endoscopy allows direct visualization of internal lesion. Though ultrasound abdomen was done initially but endoscopy clinched the diagnosis in this baby.

Most of the cases of hyperplastic polyps reported in literature have been removed by surgical laparotomy. But endoscopic snare polypectomy or endoscopic mucosal resection is preferred option in present practice. However, at very early age, removing giant gastric polyps using endoscopy is challenging because bleeding from feeding vessel could induce unexpected hypovolemic shock [8]. Even in a 56 year old, severe bleeding from such polyp has been described where endoscopic measures failed to control bleeding and surgical wedge resection was needed [9]. Present case was also subjected to laparoscopic removal in view of large size and age of the infant.

Endoscopic submucosal dissection (ESD) can avoid the problems of endoscopic mucosal resection for better hemostasis under direct vision. Successful ESD has been reported in children even as young as 21month old [7] but it needs immense expertise to perform in young infant like the present case.

In conclusion hyperplastic polyp is a very uncommon etiology of hematemesis in infants. Endoscopy gives a quick and definitive diagnosis and can guide for the proper management depending on availability of expert hands, clinical condition of the patient and the age of the child.