Endoscopic management of nonampullary duodenal polyps.
ABSTRACT Duodenal polyps are a rare finding in patients presenting for gastroscopy, being found in 0.3-4.6% of cases. The majority of patients are asymptomatic. The most common lesions necessitating removal are duodenal adenomas which should be differentiated from other mucosal lesions such as ectopic gastric mucosa, and submucosal lesions such as carcinoids and gastrointestinal stromal tumours (GISTs). Adenomas can occur sporadically or as part of a polyposis syndrome. Both groups carry malignant potential but this is higher in patients with a polyposis syndrome. The majority of sporadic duodenal adenomas are flat or sessile and occur in the second part of the duodenum. Historically duodenal adenomas have been managed by radical surgery, which carried significant mortality and morbidity, or more conservative local surgical excision which resulted in high local recurrence rates. There is growing evidence for the use of endoscopic mucosal resection (EMR) techniques for treatment of sporadic nonampullary duodenal adenomas, with good outcomes and low complication rates. Endoscopic submucosal dissection (ESD) carries greater risk of complications and should be reserved for experts in this technique. Patients with sporadic duodenal adenomas carry an increased risk of colonic neoplasia and should be offered colonoscopy. The impact of endoscopic resection on the course of polyposis syndromes such as familial adenomatous polyposis (FAP) needs further study.
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ABSTRACT: The authors studied 51 patients who had small bowel tumors that contained adenomatous epithelium. These rare lesions were identified among 392,000 surgical pathology cases seen during a 62-year period. Grossly and histologically, adenomas arising in the mucosa of the small intestine are similar to the adenomas found in the colon. Of the 51 patients, 18 had adenomas, and 33 had tumors that contained both adenoma and carcinoma in the same lesion, including five intramucosal and 28 invasive carcinomas. The location of the tumor usually determined which clinical problems were produced. The data indicate that adenomas originating in the small bowel mucosa probably are premalignant lesions and that many primary adenocarcinomas of the small intestine arise in adenomas. Of the authors' 130 apparently primary small bowel carcinomas (including the papilla of Vater), 33 (25%) histologically demonstrated adenomatous epithelium in the same lesion. Factors associated with an increased chance of finding carcinoma in an adenoma include adenoma type, size of lesion, location, and multicentricity. Carcinomas appear to develop more frequently in papillary (villous) adenomas than in ordinary adenomas. The larger the lesion is, the more likely carcinoma will be identified. Adenomas involving the ampulla contain carcinoma more often than do lesions found elsewhere in the duodenum and small intestine. Three patients had multiple adenomatous polyps of the small bowel; two of these individuals also had duodenal carcinomas. Various problems in pathologic diagnosis and clinical management are discussed.Cancer 09/1981; 48(3):799-819. · 5.20 Impact Factor
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ABSTRACT: During a 6-year period from 1976 to 1982, 7346 gastrointestinal endoscopy procedures were performed in the Surgical Endoscopy Unit of Beth Israel Medical Center. This report summarizes our experience with 443 gastroduodenal polyps excised in 257 patients. Of these, 123 were male and 134 female, ranging in age from 19 to 92. The vast majority were between the ages of 60 and 80. With one exception, polyps varied from 0.3 cm to 6 cm in diameter (one patient had a 12-cm hyperplastic polyp). There were 399 gastric polyps in 238 patients and 44 duodenal polyps in 19 patients. Of the polyps excised, 282 (63.1%) were sessile and 161 (36.9%) were pedunculated. The majority of the patients (185) had a single polyp and 72 patients had two or more polyps. Seven patients with multiple polyps had Peutz-Jeghers Syndrome and two patients had Gardner's Syndrome. Hyperplastic polyps constituted the majority (62%) of the polyps. These polyps have minimal, if any, tendency to degenerate into carcinoma. In contrast, adenomatous gastroduodenal polyps (21%) have a definite propensity to degenerate into carcinoma. This occurred in 9.6% of the patients in this series. There were no deaths and only two complications (bleeding) in this series.Annals of Surgery 09/1984; 200(2):175-80. · 6.33 Impact Factor
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ABSTRACT: In view of the rarity of small-bowel epithelial neoplasms as compared with the case for the large bowel, evidence for an adenoma-carcinoma sequence in the small bowel was studied based on a search for data in the medical literature for the years 1927 through 1986. Sufficiently defined data were found for comparison of 185 benign adenomas, 76 adenoma-with-carcinomas, and 1333 carcinomas in patients without familial polyposis disease and for 63, five, and 30, respectively, in patients with disease. For patients without polyposis, it was found that (1) 29.8% of all small-bowel adenomas (33.6% if those at Vater's ampulla are excluded) showed malignancy; (2) the mean and median ages were lower for benign adenoma than for adenoma-with-carcinoma and carcinoma, although the ratios by sex were the same; (3) there is a nearly identical spatial distribution of the three types of epithelial neoplasms within the small bowel; and (4) both the frequency of finding adenomatous residues existing in continuity with carcinoma and the life history of the adenoma-carcinoma sequence are similar in the small bowel as in the large. In comparing these results with those from patients with familial polyposis disease, it was particularly noted that (1) the only difference was that adenomas in familial polyposis occurred earlier and multiply, and (2) the spatial distributions of adenomas and carcinomas for both cases were closely similar. It is therefore postulated that the adenoma-carcinoma sequence is as significant in the small bowels as in the large. A hypothesis regarding the relationship of epithelial neoplasms in people with and without familial polyposis disease is suggested.Cancer 09/1990; 66(4):702-15. · 5.20 Impact Factor
Ther Adv Gastroenterol
(2012) 5(2) 127 –138
© The Author(s), 2011.
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Therapeutic Advances in Gastroenterology Review
Duodenal polyps are reported in 0.3–4.6% of
patients attending for upper gastrointestinal
endoscopy [Ghazi et al. 1984; Hochter et al. 1984;
Jepsen et al. 1994; Reddy et al. 1981]. Management
of these polyps is dependent on symptoms, histo-
pathology and endoscopic features. This review
focuses on the endoscopic management of non-
ampullary duodenal polyps and in particular duo-
Historically duodenal adenomas have been man-
aged by radical surgery or more conservative
local surgical excision. However, these approaches
have carried significant morbidity and mortality
risks, plus a high recurrence rate following
local excision. For these reasons, endoscopic
management of duodenal adenomas has become
increasingly popular. However there is a lack
of published evidence regarding the optimal
endoscopic management of duodenal polyps,
both sporadic and in those associated with a
polyposis syndrome. Small case series show
promising but variable results of endoscopic
management. A recent UK National Institute for
Health and Clinical Excellence (NICE) identi-
fied the lack of data in this field [NICE, 2010]
Endoscopic treatment of duodenal polyps pro-
vides a challenge both in terms of accurate diag-
nosis, staging and endoscopic resection in the
presence of the thin duodenal wall and rich vas-
cularity. However, an endoscopic approach offers
considerable advantages in terms of organ preser-
vation, risks, recovery and length of hospital stay.
The aim of this article is to review the available
literature on endoscopic resection of duodenal
polyps and highlight the advantages and disad-
vantages of an endoscopic approach.
Endoscopic management of nonampullary
Peter John Basford and Pradeep Bhandari
Abstract: Duodenal polyps are a rare finding in patients presenting for gastroscopy, being
found in 0.3–4.6% of cases. The majority of patients are asymptomatic. The most common
lesions necessitating removal are duodenal adenomas which should be differentiated from
other mucosal lesions such as ectopic gastric mucosa, and submucosal lesions such as
carcinoids and gastrointestinal stromal tumours (GISTs). Adenomas can occur sporadically or
as part of a polyposis syndrome. Both groups carry malignant potential but this is higher in
patients with a polyposis syndrome. The majority of sporadic duodenal adenomas are flat or
sessile and occur in the second part of the duodenum. Historically duodenal adenomas have
been managed by radical surgery, which carried significant mortality and morbidity, or more
conservative local surgical excision which resulted in high local recurrence rates. There is
growing evidence for the use of endoscopic mucosal resection (EMR) techniques for treatment
of sporadic nonampullary duodenal adenomas, with good outcomes and low complication
rates. Endoscopic submucosal dissection (ESD) carries greater risk of complications and
should be reserved for experts in this technique. Patients with sporadic duodenal adenomas
carry an increased risk of colonic neoplasia and should be offered colonoscopy. The impact
of endoscopic resection on the course of polyposis syndromes such as familial adenomatous
polyposis (FAP) needs further study.
Keywords: adenoma, carcinoid, duodenum, endoscopic mucosal resection, endoscopic
submucosal dissection, familial adenomatous polyposis, gastrointestinal stromal tumour
Pradeep Bhandari, MBBS,
Peter John Basford, BSc,
Portsmouth Hospitals NHS
Trust – Gastroenterology,
Queen Alexandra Hospital,
Cosham, Portsmouth, UK
429590 TAG521756283X11429590P Basford and P BhandariTherapeutic Advances in Gastroenterology
Therapeutic Advances in Gastroenterology 5 (2)
Types of duodenal polyps
A variety of lesions can be found in the duodenum
on endoscopic examination. These lesions can be
distinguished based on endoscopic appearance,
endoscopic ultrasound (EUS) and histology.
Biopsy is recommended to determine histology
and thus guide management.
Inflammatory fibroid polyps are a rare finding in
the duodenum, being much more common in the
stomach [Wysocki et al. 2007]. They are usually
submucosal which makes accurate endoscopic
diagnosis difficult as histopathology is rarely diag-
nostic. Use of EUS may aid diagnosis prior to
resection. If small and asymptomatic these lesions
can be left alone. However polyps up to 12.5 cm
in size have been reported and large symptomatic
lesions warrant removal [Ott et al. 1980].
Carcinoid tumours of the duodenum are rare,
accounting for less than 5% of all carcinoids. They
arise from the submucosa and hence biopsies can
be nondiagnostic. In a case series of 27 lesions,
59% were found in the first part of the duodenum
[Zyromski et al. 2001]. Data on endoscopic resec-
tion of carcinoid tumours is limited to very small
case series. Endoscopic resection is feasible for
carcinoids <1 cm and possibly up to 2 cm in diam-
eter. EUS assessment is required prior to resection
to ensure that the lesion does not involve the mus-
cularis propria [Ahmad et al. 2002; Dalenback and
Havel, 2004; Karagiannis et al. 2009; Pungpapong
et al. 2006; Shim and Jung, 2005; Urso et al. 2007;
Zyromski et al. 2001]. The risk of perforation and
bleeding can be high due to the submucosal origin
of carcinoids, plus the rich vascular supply and
thin wall of the duodenum. Therefore, resection of
carcinoids in the duodenum should be reserved
for experts working in high-volume centres with
experience of performing endoscopic mucosal
resection (EMR) in the duodenum.
Solitary Peutz–Jeghers-type polyps can be found
in the duodenum in the absence of Peutz–Jeghers
syndrome although there are only a handful of
case reports. These lesions have been described as
having a lobular or nodular surface, whitish col-
our and whitish spots on the surface. Endoscopic
removal is indicated as there is a small risk of
malignant transformation [Suzuki et al. 2008].
Gastrointestinal stromal tumours (GISTs) are
submucosal tumours and cannot be diagnosed by
standard endoscopy or biopsy. EUS is key in con-
firming the diagnosis and determining the layer of
origin. Those arising from the muscularis mucosae
can potentially be removed by EMR but the
majority will require surgery. GISTs of the duo-
denum are less common than gastric GISTs but
more likely to be symptomatic [Miki et al. 2010].
Prognosis of duodenal GISTs compared with
gastric GISTs is debatable with some authors
suggesting recurrence after resection may be more
frequent, whilst others report a more favourable
prognosis [Miki et al. 2010; Yang et al. 2009].
Gastric heterotopia is most commonly found as
multiple small polyps in the duodenal bulb as
reported by Jepsen and colleagues [Jepsen et al.
1994]. However, other retrospective studies of
duodenal polyps report no cases of gastric hetero-
topias, raising the possibility that as a relatively
common finding, these lesions may not be
reported by many endoscopists. They have no
malignant potential or clinical significance and do
not require any endoscopic treatment.
Brunner’s gland tumours are extremely rare with
a prevalence of less than 1 in 10,000 in an autopsy
series [Osborne et al. 1973]. These lesions are
predominately found in the duodenal bulb and
small polyps are usually asymptomatic. They usu-
ally follow a benign course but dysplasia and
malignancy have occasionally been reported.
Larger polyps tend to be pedunculated and can
present with upper gastrointestinal haemorrhage
requiring endoscopic intervention [Mukherjee
et al. 1999; Walden and Marcon, 1998].
Rarer duodenal tumours such as those described
so far only constitute a small minority of the
lesions for which duodenal endoscopic resection is
indicated. The bulk of experience in this area is in
the treatment of duodenal adenomas. Duodenal
adenomas have malignant potential in a similar
fashion to colonic adenomas [Sellner, 1990;
Spigelman et al. 1994]. This is the case both in
patients with polyposis syndromes such as familial
adenomatous polyposis (FAP) and also in those
with sporadic duodenal adenomas (SDAs). The
risk of carcinoma is greater in ampullary adeno-
mas compared with nonampullary, and increases
with the size of adenoma [Eswaran et al. 2006;
Perzin and Bridge, 1981].
P Basford and P Bhandari
Historical series of surgical resection specimens
show the majority of patients to be symptomatic,
usually presenting with advanced lesions [Perzin
and Bridge, 1981; Sellner, 1990]. With the increas-
ingly widespread use of endoscopy over the past
few decades, duodenal adenomas are being
detected at an earlier and often asymptomatic
stage. Recent series of endoscopically managed
duodenal polyps report 66–80% of patients to be
asymptomatic at the time of diagnosis [Abbass
et al. 2010; Alexander et al. 2009; Perez et al. 2003;
Takahashi et al. 2009]. However, all adenomas
carry a risk of malignant potential, so depending
on the patient’s fitness and life expectancy, resec-
tion of adenomas should be considered.
Duodenal adenomas in familial
Duodenal adenomas occur in up to 90% of
patients with FAP, most commonly at the ampulla,
peri-ampullary region or distal duodenum, which
is thought to be in part due to the exposure of the
duodenal mucosa to bile in a predisposed patient
[Bulow et al. 2004; Gallagher et al. 2006; Spigelman
et al. 1989]. The lifetime risk of duodenal cancer
in patients with FAP is estimated to be 3– 5%
[Bulow et al. 2004; Groves et al. 2002; Lepisto
et al. 2009; Vasen et al. 1997]. Duodenal cancer
and desmoids tumours are now the main cause of
death in patients with FAP, rather than colorectal
cancer [Arvanitis et al. 1990; Spigelman et al.
1989]. A staging system for assessing the severity
of the duodenal polyp burden was developed by
Spigelman and colleagues (see Table 1). This has
been used to assess the duodenal polyp burden in
patients with FAP and predict the risk of devel-
oping duodenal cancer.
The risk of developing duodenal cancer is great-
est for patients with stage IV disease, with rates of
7–36% described over follow-up periods of 7.6–
10 years [Bulow et al. 2004; Groves et al. 2002].
This risk is confirmed in studies of duodenal
resection specimens of patients with stage
IV disease which revealed unsuspected cancer in
28–31% of cases [Gallagher et al. 2004; Penna
et al. 1998]. In comparison the risk of developing
duodenal cancer in stage 0–III disease over a sim-
ilar period is low at 0.7% [Bulow et al. 2004].
Progression to higher stages occurs over time with
one study showing 15% of patients progressing
from stages 0–III to stage IV disease over a period
of 8 years [Bulow et al. 2004]. The risk of develop-
ing stage IV disease by age 70 is estimated to be
between 20% and 50% [Bjork et al. 2001; Bulow
et al. 2004; Heiskanen et al. 1999].
There is evidence that use of nonsteroidal anti-
inflammatory drugs (NSAIDs) may reduce pro-
gression and even cause regression of small
adenoma [Phillips et al. 2002]. These potential
advantages need to be balanced against potential
cardiovascular and renal side effects and the risk
of gastrointestinal bleeding.
Surgical management involves duodenectomy with
or without preservation of the pancreas and pylorus.
This carries significant morbidity and mortality
risks, greater than those for non-FAP patients
undergoing similar surgery [Gallagher et al. 2004;
Ruo et al. 2002]. This may be related to increased
complexity of surgery due to previous prophylactic
colectomy and the presence of desmoids tumours in
patients with Gardener’s syndrome. Surgical duo-
denotomy and polypectomy has proven ineffective
with high rates of recurrence [Penna et al. 1998].
Surveillance of duodenal familial
In view of this high risk of duodenal cancer in
patients with advanced duodenal polyposis, upper
gastrointestinal endoscopic surveillance has been
proposed, with examinations beginning from age
25–30 [Cairns et al. 2010; Gallagher et al. 2006].
Forward and side viewing endoscopes should be
used to provide adequate visualization of all the
duodenal mucosa [Bulow et al. 2004; Groves et al.
2002]. Recent studies have shown that the use of
Table 1. Spigelman grading of duodenal adenomas in familial adenomatous polyposis.
Number of polyps
Stage 0 = 0 points; stage I = 1–4 points; stage II = 5–6 points; stage III = 7–8 points; stage IV = 9–12 points.
Therapeutic Advances in Gastroenterology 5 (2)
indigocarmine chromoendoscopy leads to greater
numbers of duodenal adenomas being detected in
patients with FAP and an upgrading of the
Spigelman stage in 12% of patients [Dekker et al.
2009; Picasso et al. 2007]. Patients with no visible
polyps detected have been shown to have adeno-
matous tissue on random biopsies in up to 7.6% of
cases. However, this approach may no longer be
necessary with the more widespread use of chro-
moendoscopy and electronic-imaging techniques
such as NBI (Narrow Band Imaging), FICE
(Flexible Spectral Imaging Colour Enhancement)
and iScan enhancing pickup of small adenomas.
The frequency of endoscopic examinations is
determined by the Spigelman stage, with a shorter
duration between examinations for more advanced
stages, the aim being to detect stage IV disease
before duodenal or ampullary cancer has devel-
oped. Patients with stage 0 or I disease receive
repeat surveillance endoscopy after 5 years, those
with stage II disease after 3 years and those with
stage III disease every 1–2 years. Patients found to
have stage IV disease should be referred to a pan-
creato-biliary surgeon for consideration of prophy-
lactic duodenectomy [Groves et al. 2002]. There is
a fair degree of agreement in published recom-
mendations regarding the frequency of endoscopic
surveillance in patients of a specific Spigelman
stage. Recommendations differ slightly in the use
of imaging, chemoprophylaxis and endoscopic
intervention; see Table 2
Duodenal surveillance in this group of patients
has not been proven to improve survival. A deci-
sion analysis study suggested only a modest ben-
efit in terms of life expectancy [Vasen et al. 1997].
Optimum management of patients with lesser
stages of disease has yet to be determined. The
advent of EMR has led to a new potential thera-
peutic option for large flat duodenal polyps in
FAP. This has been proposed for patients with
stage II and III disease [Groves et al. 2002] and in
a small series has been shown to downstage dis-
ease in a proportion of patients, but with a signifi-
cant complication rate of 24% [Gallagher et al.
2006]. At present it is not clear whether endo-
scopic intervention significantly alters the course
of the disease, or improves survival or quality of
life in patients with a significant duodenal polyp
burden. However, it is our current practice to
endoscopically resect all large duodenal adeno-
mas in patients with FAP unless there is suspicion
of advanced histology and submucosal invasion.
Other endoscopic options include argon plasma
coagulation (APC), photodynamic
(PDT) and thermal ablation. In our view APC is
the only other modality which has a role, when
used for eradication of tiny adenomas less than 5
mm in size, which are often very numerous. Until
more data is available, endoscopic treatment
should be individualized based on the patient’s
overall polyp burden, size and location of polyps,
comorbidities and patient preferences. Further
studies are needed in this area to determine the
impact of endoscopic intervention on the course
of duodenal disease in FAP.
Sporadic duodenal adenomas
Nonampullary SDAs are those which arise in
patients without a known polyposis syndrome.
They are usually solitary and the majority are ses-
sile or flat rather than pedunculated [Ahmad et al.
2002; Apel et al. 2005; Honda et al. 2009; Kedia
Table 2. Recommendations for duodenal familial adenomatous polyposis surveillance.
Bulow et al.
Gallagher et al.
Groves et al.
5 yearly endoscopy
5 yearly endoscopy
3 yearly endoscopy
5 yearly endoscopy
5 yearly endoscopy
2–3 yearly endoscopy
5 yearly endoscopy
5 yearly endoscopy
3 yearly endoscopy +
1–2 yearly endoscopy
(consider GA (General
Anaesthetic)) + endoscopic
31–2 yearly endoscopy1–2 yearly endoscopy
+/− endoscopic therapy
4 EUS Consider SurgeryEUS/CT Consider
EUS, endoscopic ultrasound; CT, computed tomography; GA (General Anaesthetic)..
P Basford and P Bhandari
et al. 2010; Kim et al. 2010]. The mean age
at diagnosis is usually in the seventh decade
and incidence is approximately equal amongst
men and women. The majority of patients are
asymptomatic at the time of diagnosis, although
bleeding, anaemia and abdominal pain are the
commonest reported symptoms.
Around 80–94% of SDAs are found in the second
part of the duodenum with mean size in various
series ranging from 13 to 29 mm [Alexander et al.
2009; Apel et al. 2005; Honda et al. 2009; Kim
et al. 2010; Lepilliez et al. 2008]. Contrast radiog-
raphy is unreliable in detecting duodenal adeno-
mas, because of the flat or sessile nature of the
majority of lesions, and the vast majority are
detected during upper gastrointestinal endoscopy.
These morphological features plus their tendency
to grow along folds means that duodenal adeno-
mas can be more difficult to detect than colonic
adenomas and may be missed by the untrained
eye (Figures 1 and 3). Whilst the risk of malignant
transformation of SDAs is lower than that of duo-
denal adenomas in patients in FAP, these lesions
do carry malignant potential and removal is rec-
ommended. Historical case series of surgically
resected adenomas in symptomatic patients show
cancer prevalence rates in the resected polyps of
between 33% and 47%. The risk of carcinoma-
tous change in an asymptomatic group with duo-
denal adenomas detected at endoscopy is harder
to quantify, but is likely to be far lower [Galandiuk
et al. 1988; Jepsen et al. 1994; Miller et al. 1980;
Sellner, 1990; Witteman et al. 1993].
Treatment strategies involve radical surgical resec-
tion of the duodenum such as Whipple’s pancrea-
tectomy, pylorus preserving pancreatectomy (PPP)
or pylorus and pancreas preserving duodenectomy
(PPPD). These procedures carry a mortality risk of
1–6.4% and morbidity risk of 37–41% [Cameron
et al. 2006; Mukherjee et al. 2009].
Local surgery involving duodenotomy and local
excision or wedge excision have shown high rates
of recurrence and still carry significant operative
risk and is not currently practised by most sur-
geons [Galandiuk et al. 1988; Haglund et al.
1985]. This has led to a surge in endoscopic
assessment and resection of duodenal adenomas.
The principles of EMR at other sites apply equally
to duodenal adenomas. The lesion is first care-
fully assessed to determine size, involvement
of mucosal folds and proportion of the circumfer-
ence of the duodenal lumen involved. The rela-
tionship of the adenoma to the Ampulla of Vater
should be determined, using a side-viewing endo-
scope. Delineating the borders of the adenoma
may be aided by the use of chromoendoscopy.
Intravenous glucagon or hyoscine should be given
during assessment or resection to limit duodenal
peristalsis and improve the view and access to the
Careful evaluation is required before planning
any endoscopic intervention. Endoscopic assess-
ment should focus on endoscopic resectability of
the lesion and detection of any features which
may predict submucosal invasion and hence make
endoscopic treatment unsuitable. Features which
suggest higher risk of submucosal invasion include
a depressed element (IIc component of the Paris
classification), type 5 Kudo’s pit pattern, surface
Figure 1. Small duodenal adenoma.
Figure 2. Duodenal EMR base closed with clips.