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
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
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
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
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
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.
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.
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
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)
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.
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).
