Duodenal adenomas Management. Dr Stratis Alexandridis Consultant Gastroenterologist BRI
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1 Duodenal adenomas Management Dr Stratis Alexandridis Consultant Gastroenterologist BRI
2 Introduction Ampullary and non ampullary polyps of the duodenum are diagnosed within and outside genetic syndromes. Adenomas are the most common encountered lesions although hyperplastic polyps and other mucosal tumours also occur. Similar to colonic polyps have malignant potential
3 Introduction Endoscopic identification of duodenal adenomas can also be hampered by the similarly appearing, adjacent normal villiform duodenal mucosa (false negative results in % of patients) Endoscopic Resection (ER) is the first line treatment Limited resections and Pancreaticoduodenectomy remains as the standard treatment for large and complex adenomas which are technically impossible to remove using endoscopic techniques Optimal method of ER depends upon a range of factors including lesion location, size and morphology.
4 Epidemiology % of patients attending Upper GI endoscopy Absence of randomised control trials, recommendations based on observational studies and clinical experience. Ampullary and non ampullary polyps
5 Epidemiology of duodenal polyps associated with genetic syndromes 90% of Familial Adenomatous Polyposis (FAP) Syndrome cumulative risk of duodenal cancer is 3%-10% Spigelman system
6 Epidemiology of duodenal polyps associated with genetic syndromes MUTYH-associated polyposis (MAP) Duodenal adenomas -17%-25% of patients with MAP, lifetime duodenal cancer risk 4%
7 Ampullary adenomas Adenomas: most common benign lesions of the ampulla but with potential to malignant transformation (15-60% of ampullary adenomas harbour foci of adeno ca). Sporadic or in the setting of Familial adenomatous syndromes (FAP or MUTYH polyposis)
8 Ampullary adenomas work up Duodenoscopy with a side view scope. Preferably HD endoscopy with digital chromoendoscopy (NBI) Chromoendoscopy with indigocarmine to identify margins. EUS to assess relationship with Common Bile Duct (CBD) and Pancreatic Duct (PD) and intraductal extention (IDE)
9 Non Ampullary adenomas Duodenoscopy with a straight and or a side view endoscope. Preferably HD with NBI. Chromoendoscopy with indigocarmine EUS assessment is not mandatory.
10
11 Ampullary adenomas FAP Sporadic Duodenoscopy with NBI and chromoendoscopy with Indigocarmine +Biopsies EUS Offer colonoscopy Spigelman score Endoscopic surveillance for stage I, II, III stage I and II every 2-3 y stage III every 6-12 mo Surgical review for stage 4 LGD and < 1cm LGD and >1 cm HGD /adenoca or Non resectable endoscopically Endoscopic surveillance Endoscopic Resection if possible Surgery Intraductal inv. > 1cm Annual Endoscopic follow up 3-6 months and then annually for 2 years Intraductal inv. < 1cm
12 Non Ampullary Adenomas. Duodenoscopy with NBI and chromoendoscopy with indigocarmine + Biopsies Offer colonoscopy LGD and < 1 cm LGD and > 1 cm HGD Advanced pathology / not amenable to endoscopic treatment Surveillance Consider Endoscopic excision Surgical review / endoscopic treament Surgical review Annual (for two years, then if unchanged one further OGD two years later) Currently little guidance Endoscopic follow up 3-6 months and then annually for 2 years
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