The repeat gastric antral biopsy specimens showed normal appearances; no Helicobacter‐like organisms were identified. The duodenal biopsy specimens showed an unusual appearance, with one polypoid fragment showing an area of elongated crypts and villi with serrated profiles (fig 1B,C1B,C).). The appearances were similar to those of a hyperplastic polyp of the colon. The duodenal mucosa in this area was also focally covered by gastric‐type surface epithelium—apical diastase‐periodic acid‐Schiff‐positive mucin glands were present (fig 1D1D)) in contrast with the brush border and scattered goblet cells usually present in duodenal surface epithelium. No Helicobacter‐like organisms were identified in association with this gastric‐type surface epithelium. The epithelium in this area of polypoid change showed reactive features but there was no evidence of dysplasia.
Several types of polyps can occur in the duodenum (table 11). Duodenal polyps are most commonly sessile but may also be pedunculated in nature. Ectopic gastric mucosa and polyps related to Brunner's gland hyperplasia are among the most commonly encountered in routine surgical practice. Adenomas are often situated at or adjacent to the ampulla of Vater and may be associated with underlying invasive carcinoma that is not apparent in superficial biopsy specimens.
The case here highlights the fact that polypoid mucosa may sometimes have an unusual endoscopic and histological appearance. In this case, the presence of focal surface‐type gastric epithelium in the area of duodenal polypoid change suggests that the hyperplastic polyp‐like appearance is most likely to represent an unusual form of regenerative change in response to one or more episodes of inflammatory mucosal damage occurring in the duodenum. The differential diagnosis of this lesion would include a serrated adenoma. Serrated adenomas are very uncommon lesions in the duodenum and have been described in association with familial adenomatous polyposis.When assessing serrated polyps, the key feature that enables a diagnosis of serrated adenoma is the presence of nuclear atypia, which is evenly distributed throughout the length of the crypts and which extends to the surface of the polyp. In our case, nuclear atypia was present but was much less marked at the surface of the lesion.
Lesions with the appearances of hyperplastic polyps have rarely been previously described in the duodenum. However, these have almost always occurred in the setting of ectopic gastric mucosa of specialised type and therefore show appearances that more closely mimic hyperplastic polyps of the stomach rather than hyperplastic polyps of colonic type. When these lesions occur in the duodenum they may be associated with colonisation by Helicobacter‐like organisms.6 We have found only one previous report of hyperplastic polyps occurring in the duodenum, in which two cases are described. One patient presented with melaena after aspirin usage, and endoscopy showed gastric antral erosions and a 3 mm duodenal bulb polyp. A second patient presented with dyspepsia, and endoscopy showed a hiatus hernia and a 5 mm duodenal bulb polyp. The polyp from the first patient was described as comprising colonic‐type mucosa, although the figure suggests that a mixture of gastric‐type surface epithelium and goblet cells was present. The polyp from the second patient showed a serrated appearance but almost entirely comprised gastric‐type surface epithelium with no goblet cells.7 The polyp in our case showed appearances that were very similar to those of the first patient in this earlier report. Interestingly, both of the polyps in this report presented as isolated lesions in the duodenal bulb, whereas the lesion in our case presented as pale ridges in the distal duodenum.
This report highlights the rare occurrence of hyperplastic polyps in the duodenum. It is important to differentiate these lesions from serrated adenomas. It seems that these lesions most commonly occur in the setting of peptic ulcer disease or other forms of erosive gastritis and duodenitis.
We searched the medical records of 50 114 consecutive patients that had a first diagnostic esophago-gastroduodenoscopy between January 2004 and December 2009. Most of patients had visited the gastrointestinal department and had dyspeptic symptoms. We used the electronic database of St. Vincent’s Hospital, the Catholic University of Korea and searched the keywords of “duodenal polyp” (K317; International Statistical Classification of Disease, the 10th Revision, ICD-10) or “benign neoplasm of duodenum” (D132). Cases were accrued by searching the database. Among 510 cases diagnosed endoscopically with duodenal polyps, 221 cases that underwent tissue biopsy were enrolled. Lesions of the ampulla of Vater (D135) and submucosal tumors (D372) - cysts, lipomas, lymphangiectasia, and gastrointestinal stromal tumors, were excluded and were traditionally recognized as submucosal lesions (Table (Table1).1). Endoscopic and histological features of the ampullary tumors and submucosal tumors are shown in Figure Figure1.1. This study protocol was approved by the Ethics Committee of the Catholic University of Korea.
Data collected on the study subjects included age, gender, family history of polyposis, and location, size, and histology of the duodenal polyp. All tissue specimens were obtained using biopsy forceps (FB-19K-1, Olympus, Tokyo, Japan), polypectomy, or endoscopic mucosal resection. The size of the polyp was measured endoscopically using the “open biopsy forceps method”. Biopsy forceps with a diameter of 4 mm when fully opened were used. The forceps were withdrawn in the open position toward the endoscope tip as far as possible, until both cups were fully visualized. The open forceps was then advanced until they were aligned against the largest diameter of the polyp, with the tip of the endoscope still placed at approximately 3 to 4 cm from the polyp.
The endoscopic, histological, and clinical characteristics of the duodenal polyps were recorded; subsequently, the duodenal polyps were divided into non-neoplastic and neoplastic lesions. The non-neoplastic lesions included Brunner’s gland hyperplasia, Brunner’s gland hamartoma, ectopic gastric mucosa, ectopic pancreas, hyperplastic polyps, and inflammatory polyps. The neoplastic lesions included adenomas, carcinoid tumors, and miscellaneous lesions. We analyzed the differences of age, sex, size, shape, location and multiplicity between the non-neoplastic and neoplastic lesions. In addition, we evaluated the clinical features of the duodenal hyperplastic polyps. Each case was classified as H. pylori positive or negative according to the histological results (CLO test or silver stain) using two pieces of biopsy specimen taken from the antrum and the body of the stomach.
All data were recorded on standard forms and computer analyzed. The Mann-Whitney U-test was used to compare the continuous variables between the two groups. Differences between dichotomous variables were evaluated with the Pearson Chi-square test. Calculations were performed with the SPSS package software (SPSS version 12.0, Chicago, IL, USA). P values less than 0.05 were considered significant.
Therapeutic resection of duodenal polyps
For patients with neoplastic lesions, 20 (80%) of 25 patients had therapeutic removal and 16 (64%) patients had successful endoscopic resection. Two of the remaining five patients have chosen surveillance endoscopy, because the lesion was small and the patients had co-morbid diseases. Two cases were lost to follow-up. One patient with a metastatic lesion from esophageal cancer has received radiation therapy.
Evaluation of non-ampullary duodenal polyps: Comparison of non-neoplastic and neoplastic lesions
Last edited by Medical Photos; 09-20-2015 at 07:46 PM.
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