gastric hamartomatous inverted polyp ( ghip ) is a rare form of gastric polyp . the accurate diagnosis of ghip is difficult preoperatively because the main lesion is located in the submucosa or within the muscularis mucosae . here , we report the successful resection of a submucosal tumor ( smt )  type ghip by endoscopic submucosal dissection ( esd ) . a 55-year - old woman presented after a gastric tumor in the greater curvature of the upper gastric body had been detected incidentally on an upper gastrointestinal x - ray series performed during a routine medical examination . endoscopy revealed a gastric smt measuring 15  mm in diameter in the greater curvature of the upper gastric body . the elevated lesion was covered with normal mucosa , and an irregular depression was evident at the top of the smt ( fig .  1 ) . endoscopic ultrasonography ( 20  mhz ) showed a heterogeneous tumor with small , cystic , anechoic spots originating from the second layer , indicating that the main lesion was located in the deep mucosal layer or within the muscularis mucosae ( fig .  2 ) . the patient was clinically asymptomatic , with no contributory family history or abnormal laboratory data . physical examination and abdominal computed tomography revealed no abnormalities . endoscopy shows a gastric submucosal tumor ( smt ) measuring 15  mm in diameter in the greater curvature of the upper gastric body . the tumor was found incidentally in a 55-year - old woman on an upper gastrointestinal x - ray series performed during a routine medical examination . endoscopic ultrasonography shows a heterogeneous tumor with small , cystic , hypoechoic spots originating from the second layer . to obtain an accurate diagnosis , because the tumor had the shape of an smt , we considered that complete resection with conventional endoscopic mucosal resection ( emr ) would be difficult . we used an insulation - tipped diathermic knife ( it knife2 ; olympus , tokyo , japan ) to perform an en bloc resection of the smt by esd without any complications ( fig . smooth - muscle fibers were located in the submucosal layer , with branching from the proliferation of smooth - muscle bundles . the surface of the polyp was covered by gastric mucosa without atypia . according to these histological findings , the pathological diagnosis was ghip ( fig .  4 ) . histopathological examination shows cystic , dilated , hypertrophic pseudopyloric gland proliferation and smooth - muscle fibers located in the submucosal layer , with branching from the proliferation of smooth - muscle bundles ( hematoxylin and eosin ,   40 ) . ghips are usually found as a part of peutz    jeghers syndrome or cowden disease but are rarely solitary or asymptomatic 2 . ghips are characterized pathologically by cystic , dilated , hypertrophic pseudopyloric gland proliferation and by smooth - muscle fibers located in the submucosal layer , with branching from the proliferation of smooth - muscle bundles . the main lesion in ghip is located in the submucosa or within the muscularis mucosae 3 . ghips are difficult to diagnose accurately without endoscopic or surgical resection and subsequent pathological investigation because of the inverted growth into the submucosal layer 4 . ghips without a stalk are classified as of the smt type , whereas those with a stalk are classified as of the polyp type . polyp - type ghips can be resected endoscopically by conventional emr , but conventional emr has been reliable for resecting smt - type lesions in one piece only if the lesions have a diameter of 10  mm or less . for smt - type lesions larger than 10  mm in diameter , surgical resection furthermore , approximately 20  % of ghips coexist with precancerous or cancerous areas 6 
 7 
 8 . in our patient , the diameter of the smt was about 15  mm , so we selected esd rather than conventional emr to achieve a complete en bloc resection and obtain an accurate pathological diagnosis . according to a search of the pubmed database , only four reports have described ghip removal by esd 4 
 7 
 8 
 9 . an accumulation of case reports for the endoscopic resection of ghip is important , although the endoscopic and endoscopic ultrasound findings were relatively typical in the present case . esd can provide sufficient tissue for an accurate pathological diagnosis following complete en bloc resection . we therefore think that for an accurate diagnosis of ghip , en bloc resection with an esd method is warranted .
we report the case of a 55-year - old woman with a tumor in the greater curvature of the upper gastric body . the tumor was incidentally found on an upper gastrointestinal x - ray series performed during a routine medical examination . whereas endoscopy revealed a gastric submucosal tumor ( smt ) , endoscopic ultrasonography demonstrated a heterogeneous tumor with small , cystic , hypoechoic spots originating from the second layer . 
 the patient was clinically asymptomatic , with no contributory family history or abnormal laboratory data . 
 the results of a physical examination , abdominal computed tomography , and plain chest radiography were all unremarkable . 
 although the endoscopic tumor type was determined to be smt , the tumor was successfully resected by endoscopic submucosal dissection ( esd ) and subsequently diagnosed as a gastric hamartomatous inverted polyp ( ghip ) . 
 the findings of the present case highlight the importance of considering ghip as a diagnosis and indicate the utility of en bloc resection of ghip with esd .