A Rare Esophageal Inflammatory Fibroid Polyp Causing Chronic Gastrointestinal Blood Loss

A 65-year-old man was presented with intermittent melena and recurrent anemia for 1 year. He had diabetes mellitus and ischemic heart disease and was on metformin and aspirin. Upper gastrointestinal endoscopy revealed a large pedunculated polyp (7 × 4 cm) in the lower thoracic esophagus with surface ulceration and mild luminal narrowing ([ Figs. 1 ] and [ 2 ]). Initial biopsy done elsewhere showed features of glycogen acanthosis. Contrast-enhanced computed tomography thorax was done initially, which showed wall thickening in the lower esophagus with paraesophageal lymph node enlargement, which was suspicious of malignancy. Positron emission tomography–computed tomography demonstrated fibroblast activation protein inhibitor avid heterogeneously enhancing polypoidal growth in the lower thoracic esophagus, fibroblast activation protein inhibitor nonavid discrete perilesional (paraesophageal) and lower retroaortic lymph nodes, suggestive of benign lesion without any significant lymph node enlargement. After a multidisciplinary team meet, initial polypectomy followed by further management depending on the histopathology was made. Diluted adrenaline was injected to base of the polyp, and adequate lift was achieved. Prophylactically, endo-loop was applied to the base of the polyp, which was followed by endoscopic polypectomy using hot snare with hemoclip application without complications. Based on the endoscopic appearance, the differentials considered included leiomyoma, gastrointestinal stromal tumor, inflammatory fibroid polyp (IFP), schwannoma and esophageal squamous cell carcinoma. Fig. 1 Upper gastrointestinal endoscopy showing a large pedunculated polyp with surface ulceration. Fig. 2 Upper gastrointestinal endoscopy showing thick stalk of the polyp. Histopathology showed hyperplastic and focally ulcerated squamous epithelium with glycogenation. The stroma contained bland spindle cells and myofibroblasts with prominent thick- and thin-walled vessels ([ Fig. 3 ]), focal smooth muscle bundles, and diffuse eosinophilic infiltrate ([ Fig. 4 ]), diagnostic of IFP. Immunohistochemistry (IHC) was not done in this case as the pathologist confirmed classical morphology of IFP and did not recommend for IHC. The patient was followed up after 1 month, during which there has been no recurrence of symptoms or evidence of lesion recurrence in endoscopy. Fig. 3 Vascular stroma (blue arrow) with myofibroblasts (yellow arrow) suggestive of a mesenchymal polyp. Fig. 4 Scattered inflammatory cells, especially eosinophils (yellow arrow), which is pathognomonic of inflammatory fibroid polyp. IFP is a rare benign mesenchymal neoplasm first described by Vanek, most commonly arising in the gastric antrum; esophageal involvement is exceptional.[ 1 ] Histology classically demonstrates spindle cells with perivascular “onion-skinning” and eosinophil-rich inflammation.[ 2 ] Many cases harbor PDGFRA mutations, supporting a neoplastic origin.[ 3 ] Esophageal IFPs are often large and symptomatic, presenting with dysphagia or bleeding.[ 4 ] Complete endoscopic resection is curative, with excellent prognosis, minimal malignant potential, and rare documented recurrence on long-term follow-up.[ 5 ]