This document describes a case of a 32-year-old female patient presenting with abdominal pain, nausea, bloating and vomiting for 1 year. An endoscopy revealed a large pedunculated polyp in the duodenum, and imaging showed duodenal intussusception likely caused by the polyp. The patient underwent surgery to remove the 5x5x4cm polyp and had a feeding jejunostomy placed. Histopathology of the polyp found tubulovillous adenoma with low-grade dysplasia. Duodenal polyps are often asymptomatic but can cause bleeding or obstruction. Treatment involves endoscopic or surgical polypectomy depending on the size and location of the polyp.

1. Duodenal polyp
CASE PRESENTATION
DR THANA RAM PATEL
DEPARTMENT OF GENERAL SURGERY
SMS MEDICAL COLLEGE , JAIPUR

2. Demographic profile
• CR No 1011903055508
• Maya w/o Kailash Chand
• Age- 32 yrs
• Sex – female
• Religion – hindu
• Khudiyana ,Laxmangarh,Alwar rajasthan
• DOA- 25-02-2019 (gastroenterology dept then
transfer to general surgery )
• DOO- 07-03-2019
• at present patient in ward

3. history
c/o
abdomen pain * 1 yr
Nausea * 1 yr
Bloating * 1 yr
Vomitting – off and on since *1 yr
HOPI – patient is apparently healthy 1 yr back then patient having abdomen pain that
is insidious onset , localized upper abdomen, non radiating, not relieved by
medication, associated with nausea, bloating , but n/o of abdominal distension
n/h/o fever
n/h/o unconsciousness,seizure
n/h/o dizziness/fainting
n/h/o breathlessness/ dyspnea
n/h/o hemetemesis / bleeding per rectum/ constipation
n/h/o jaundice
n/h/o hematuria

4. Past history (no history of comorbidities)
N/H/O TB/DM/HTN/ASTHMA/ALLERGY
N/H/O TRAUMA / SURGERY
Family history
Younger brother having history of bleeding per rectum * 1
month duration * 1 yr back relieved by alternative medicine
prescription , no further evaluated
Personal history - veg
n/h/o smoking / tobacco chewing
Obs histoy – regular menstruation cycle

5. Clinical exams
• Patient is conscious , cooperative, well oriented to time, place , persons
• No -Icterus / palor / cynosis/ clubbing / lymphadenopathy/ pedal edema
• Average build
• afebrile
• BP 130/90 mmHg
• Pulse 96 bpm
• E4V5M6
• Heart sound S1S2 present
• Bilateral air entry present
• Per abdomen exams
• Abdomen – soft , no tenderness/ rigidity/gaurdening
• No lump palpable
• scaphoid
• Bowel sound present
• PR-NAD

6. endoscopy
• Antrum- extrensic impression present
• Pylorus- normal
• Duodenum – large pedunculated polyp
starting from D1 upto D3-D4 junction,
protruding into lumen
• Interpretation – large polyp in duodenum

7. endoscopy

8. USG
• A 49 * 45 mm size oval shaped thick walled bowel
lump with “bowel within bowel” appearance
seen in left hypochondrium s/o most likely
duodeno-jejunal intussusception. However
upstream dilatation of duodenum & stomach not
seen at present
• Multiple subcentimeter mesenteric lymph nodes
seen in para-umbilical region, largest one
measures 17*10mm
• CBD prominent measures 10mm

9. USG

10. CECT whole abdomen
• Oral contrast filled stomach is distended
shows pyloric antrum within duodenum with
evidence of mildly enhancing well define
5.8*4.9*4.4cm soft tissue density nodular sol
towards left flank with pedicle s/o
intussusception with?polyp
• Impression – s/o gastroduodenal
intussusception with possibility of large polyp

11. CECT whole abdomen

12. evaluation
• Diagnosis – duodenal polyp

13. Executed procedure
• Duodenostomy and polypectomy and primary
closure with drain placement & feeding
jejunostomy under GA
• 5*5*4 cm pedunculated polyp present at D1
causing intussusception
• Duodeum opened , polyp excised with base and
duodenum closed
• Feeding jejunostomy made
• Drain placed in subhepatic space
• Specimen taken for HPE

14. Intraop images

15. Intra-op polyp with duodenum

16. specimen

18. Post op histopathology
Specimen – excision biopsy – duodenal polyp
Gross description – single large polypoidal soft tissue with
stalk , measures 5*5*4 cm
Miscroscopic description – section examined show polypoidal
fragments of duodenal mucosa with a tubule forming &
villous forming epithelium that has cellular
pseudostratification and focally hyperchromatic nuclei ,
from the crypt base to the luminal aspect (dysplasis)
Cribriforming of glands is identified at multiple foci
No definitive evidence of invasive malignancy ,
base is free of tumor
Diagnosis – tubulovillious adenoma with low grade dysplasia

19. Post op histopathology

20. Duodenal Adenomatous polyp

21. introduction
• Adenomas account for approximately 15% of all benign
small bowel tumors
• Familial adenomas typically occur in the presence of
FAP syndrome.
• adenomas in the duodenum can be found in 50% to
90% of cases,
• Adenomas of the remaining small bowel also occur
more frequently in patients with FAP but are not as
prevalent as duodenal disease in this population of
patients.
• increasing age was identified as an independent risk
factor for adenoma development.

22. Cause- Inherited adenoma syndrome
• Cause inherited adenoma syndrome ( Adenomatous polyposis syndrome)
a) Familial adenomatous polyposis / FAP
• Adenomatous polyposis coli / APC gene on 5q  tumor suppressor gene 
gatekeeper for tumorigenesis
• Variant
 Gardner syndrome
 Turcot’s syndrome(AR)  FAP variant  medulloblastoma
 MYH variant
• Screening
• Flexible sigmoidoscopy
• APC gene testing
b) hereditary nonpolyposis colorectal cancer (HNPCC/HPNCC or Lynch’S syndrome)
 nonpolyposis (<100 colonic polyp)
– Muir-Torre syndrome: HNPCC variant with sebaceous tumours keratoacanthocytomas
– Turcot syndrome: HNPCC variant with CNS tumours  indolent glioblastoma multiforme (CNS
tumors)

23. pathogenesis
• Although these neoplasms grow slowly, FAP
patients carry a 5% lifetime risk for
development of duodenal adenocarcinoma,
which represents the leading cause of cancer-
related mortality in these patients; therefore,
routine lifelong surveillance is a priority.

24. • adenomas are
20% found in the duodenum,
30% are found in the jejunum
50% are found in the ileum.
adenomas are thought to proceed along a
similar adenoma-carcinoma sequence as
colorectal adenomas and should be
considered premalignant.

25. pathogenesis

26. Morphological manifestation

27. Clinical manifestation
• Most of these lesions are asymptomatic; most occur singly and are
found incidentally at autopsy.
• The most common presenting symptoms are bleeding and
obstruction.
• Villous adenomas of the small bowel are rare but do occur, are
most commonly found in the duodenum, and may be associated
with the familial polyposis syndrome.
• Villous adenomas have a particular propensity for malignant
degeneration and may be of relatively large size (>5 cm) in
diameter. They are usually noted occur. The malignant potential of
these lesions is reportedly between 35% and 55%.
• Adenoma most common in the periampullary region, they can
develop throughout the small bowel mucosa. Large, periampullary
duodenal adenomas may present with obstructive jaundice.

28. Endoscopic ultrasound
• Endoscopic ultrasound has recently emerged
as a useful modality in the preintervention
evaluation and may help guide management
planning.
• Endoscopic ultrasound is most useful in the
evaluation of duodenal adenomas to evaluate
depth and to determine if mucosal excision or
surgical resection is more appropriate.

29. • ultrasound will reveal evidence of biliary
obstruction, prompting upper endoscopy with
endoscopic retrograde biliary and pancreatic
duct evaluation (endoscopic retrograde
cholangiopancreatography), which will reveal
the presence of the ampullary lesion.
• CT scan may differentiate adenoma from
carcinoma, as carcinomas are often associated
with bowel wall thickening.

30. Definition
Adenoma  conventional adenoma / adenomatous polyp
1. Adenomatous  flate , papillary & >2.5 cm have more premalignant potential
2. dysplasia
• Low grade dysplasia  m/c
• High grade dysplasia (outdated terms carcinoma-in-situ & intramucosal carcinoma  should be
designated HGD)
• Advanced adenoma
3. Gross appearance
• Flate/ sessile
• Pedunculated / stalked
4. Histology
• Papillary / villous  Mc kittrick Wheellock syndrome  PG-E2  cAMP  profuse watery diarrhea
  Na , K & Cl
• Tubular _ m/c
• tubulovillous
5. Size
• <1.5cm
• 1.5-2.5 cm
• >2.5

31. Spigelman classification

32. Spigelman classification
• Recommended Surveillance Interval for Upper Gastrointestinal
Endoscopic Examination in Relation to Spigelman Classification -
Spigelman Classification (Surveillance Interval in Years)
• 0/I (5)
• II (3)
• III (1-2)
• IV (consider surgery)
To direct surveillance and treatment, patients are classified by the Spigelman
classification .
Screening endoscopy with a forward and side-viewing endoscope is
performed at regular intervals with biopsy of all suspicious, villous, or
large (>3 cm) adenomas in addition to random duodenal biopsy
specimens.
Frequency of endoscopic screening is 1 to 5 years, depending on the
Spigelman Classification.

33. Evaluation & DD
• Serrated adenoma/ serrated polyp (saw tooth appearance
or stellate shaped)
 Hyperplastic polyp  m/c serrated adenoma
• Goblet cell rich serrated polyp
• Microvesicular serrated polyp (traditional hyperplastic
polyp)  m/c sub type
• Mucin poor serrated polyp
 Sessile serrated adenoma / polyp (SSA)
 Traditional serrated adenoma (TSA)  usually
pedunculated or broad base polypoid pattern of growth
• Serrated polyp of large intestine (colon)

34. • Hamatamatous polyp  Hamartomatous / juvenile  Juvenile polyp
/retention polyp
• Cause
• Sporadic juvenile polyp  not associated with colorectal cancer risk
• hereditary  Hamartomous polyposis syndrome
 CCS
 FJP
 Juvenile polyposis syndrome /JPS
 Peutz Jeghers syndrome /PJS
 PTEN associated hamartomatous syndrome  cowden’s syndrome/CS
• Inflammatory polyp / pseudopolyp  Cause
• IBD
• Amoebic & ischemic colitis

35. treatment
• Treatment is determined by location and adenoma type.
• The options for treatment are endoscopic and surgical.
• Endoscopic or surgical polypectomy can be performed for
large adenomas.
• In the jejunum and ileum, the treatment of choice is
segmental resection.
• Although only 5% of adenomas occur in the duodenum,
they cause symptoms more frequently, and decisions about
surgical management must be carefully planned because of
the potential morbidity (20% to 30%) associated with
duodenal resection by pancreaticoduodenectomy or
pancreas-preserving duodenectomy.

36. Brunner gland adenoma
• Brunner gland adenomas represent benign
hyperplastic lesions arising from the Brunner glands of
the proximal duodenum.
• These adenomas may produce symptoms mimicking
those of peptic ulcer disease.
• Diagnosis can usually be accomplished by endoscopy
and biopsy, and
• symptomatic lesions in an accessible region can be
resected by simple excision, either endoscopically or
surgically.
• There is no malignant potential for Brunner gland
adenomas, and a radical resection should not be used.

37. Endoscopic treatment
• Endoscopic resection of these neoplasms is a safe alternative and
may delay a more aggressive and potentially morbid surgical
procedure;
• the lifelong risk of recurrence is approximately 50% after
endoscopic treatment
• endoscopic treatment
 snare excision,
 thermal ablation,
 argon plasma coagulation,
 photodynamic therapy.
• Endoscopic mucosal resection is gaining acceptance as a useful
technique for the treatment of duodenal adenomas and Brunner
gland tumors.

38. Endoscopic mucosal resection

39. • endoscopic mucosal resection, even in the setting of
large (>2 cm) sessile duodenal adenomas, had a high
success rate for complete removal; however, the risk of
delayed bleeding is significant.
• endoscopic mucosal resection is associated with an
approximate 17% risk of other complications, including
perforation, hemorrhage, and pancreatitis.
• Ablative therapy in the form of argon beam
coagulation or photodynamic therapy has been
attempted for these patients but with disappointing
results.

40. Surgical management
• The presence of high-grade dysplasia,
carcinoma in situ, or a Spigelman stage IV
classification necessitates
pancreaticoduodenectomy or pancreas-
preserving duodenectomy.
• Invasive changes or a recurrence after
polypectomy necessitates a more definitive
approach (e.g., pancreaticoduodenectomy).