Endoscopic polypectomy in the duodenum

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Endoscopic polypectomy in the duodenum Its complication by pancreatitis Edward I. Alper, Parviz foroozan, R. Bruce Johnson, William S. Haubrich,

MD MD MD MD

La Jolla, California

Nine of 12 duodenal polypoid lesions were removed endoscopically. These included epithelial and Brunner's gland adenomas, villous adenomas, and a carcinoid tumor. Two patients whose postbulbar adenomas were removed by snare and electrocoagulation developed acute, transient pancreatitis. EndoscoPic polypectomy in the duodenum is still far from commonplace primarily because of the comparative rarity of polypoid lesions in th is region. Wh iIe campi ications following removal of polyps from the colon have been uncommon, this may not be the case with respect to the duodenum. In this paper we are presenting a series of 9 duodenal polyps removed endoscopically during the past 18 months. In 2 cases the histopathologic findings suggest that the procedure may have had definite benefit for the patient. Two of the procedures were associated with morbidity afterward requiring

continued hospitalization. Two of the patients have been previously reported.1.2 Three additional cases in which a duodenal polypoid mass was endoscopically identified but not removed are discussed. MATERIALS AND METHODS In all but 1 of the cases the lesion was first noted in upper gastrointestinal radiographs taken to investigate nonspecific gastrointestinal complaints. The patients were examined with the Olympus GIF panendoscope, and the lesions were removed using the snare and electrocoagulation method with the Cameron-Miller unit, the

Table I

Endoscopic observations of polypoid lesions in the duodenum.

Patient

Age

Sex

Location of lesion

Histology

Comments (Endoscopic diagnosis)

1. VM

53

F

duodenal bulb

Brunner's gland adenoma

UGI x-ray normal 6 weeks later

2. EG

40

M

pyloric canal

adenomatous polyp

UGI x-ray normal 6 weeks later

3. VN

54

F

duodenal bulb

Brunner's gland adenoma

UGI x-ray normal 6 weeks later

4. JH

60

F

duodenal bulb

carcinoid

polypoid remnant seen on UGr 6 weeks later

5. EJ'

72

M

duodenal bulb

Brunner's gland adenoma

UGI series normal 4 weeks later

6. MS'

52

F

3rd portion of the duodenum

villous adenoma

Gastrografin UGI x-ray showed a smaller persistent defect 1 day later.

7. WI

49

M

2nd portion of the duodenum

mixed adenomas

pacreatitis (see case report)

8. CC

66

F

2nd portion of the duodenum

villous adenoma with carcinoma in situ

pancreatitis, ? perforation (see case report)

9. FF

60

M

duodenal bulb

adenomatous polyp

(endoscopic diagnosis) no complications

10. VS

72

M

2nd portion of duodenum

mucosal biopsies were normal.

not removed (aberrant mucosal fold)

11. PF

42

F

2nd portion of duodenum

mucosal biopsies normal

not removed (submucosal tumor)

12. BU

33

M

2nd portion of duodenum

none

not removed (heterotopic pancreas)

From the Division of Gastroenterology, Scripps Clinic and Research Foundation, La Jolla, California. Reprint requests: W. S. Haubrich, MD, 476 Prospect Street, La Jolla, California 92037. Volume 21, No.3, 1975

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intensity dial being set at "6." Intermittent current application was utilized, and an attempt was made in all cases to avoid contact with the opposite duodenal wall. RESULTS Our experience is summarized in Table 1. The 2 cases in which the procedure was followed by complications are presented in full. Case 1: A 49 year old man (W.I.) had recurrent chest pain for 1 month. He denied abdominal pain or any other symptoms referable to the gastrointestinal tract. He had a history of mild diabetes mellitus, controlled by diet, for 4 years. Physical examination was unremarkable. Upper gastrointestinal x-rays showed a filling defect in the proximal duodenal sweep (Figure 1a). At endoscopy, following premedication with diazepam 10 mg and atropi ne 0.8 1M, a polyp was seen on the posterolateral wall of the proximal descending portion of the duodenum. It was sessile and approximately 1 cm in diameter. There was an umbilication in the center. A wire snare was passed over the lesion, and its base was severed by electrocoagulation. The polyp was retrieved using suction as the endoscope was withdrawn. The patient tolerated the procedure well and evinced no discomfort. Approximately S hours later the patient developed severe epigastric pain associated with nausea; he vomited once but without hematemesis. The vital signs were normal. Examination of his abdomen revealed epigastric tenderness and rigidity. The bowel sounds were hyperactive. Although acute perforation of the duodenum was suspected, immediate and subsequent plain radiographs of the abdomen showed no free air. There was no anemia or leukocytosis. The serum amylase was 644 Somogyi units (normal 70-300). The patient was treated with nasogastric suction, intravenous fluids, and analgesics. Within several hours the pain had subsided, and abdominal tenderness and rigidity were gone. Subsequent serum amylase values were normal. Two days later Gastrografin radiography revealed irritability of the duodenum. After 4 days of hospitalization the patient was discharged. He has had no recurrence of symptoms. Pathologic examination of the polyp revealed a mixed adenoma containing elements of duodenal mucosa, submucosa and duodenal glands. (Figure ld). Case 2. A 66 year old woman (CC) with severe, chronic, asthmatic bronchitis had been maintained on prednisone 2S mg daily, supplemented by oral theophyline and Alupent by inhalation for the past 2 months. Upper gastrointestinal radiography was performed because of a past history of duodenal ulcer. The patient was not complaining of ulcer symptoms at the time. The x-ray study was read as showing an ulcer in the mid-portion of the duodenal bulb (Figure 2a). At endoscopy, using diazepam S mg IV as premedication, the duodenal bulb was normal, but a polypoid mass was seen just distal to the bulb on the medial wall measuring 1 cm in diameter. The surface of the mass had a reticulated appearance suggesting a villous structure. Biopsies were taken, but the mass was not removed at that time. Pathologic examination of the biopsies suggested a villous adenoma. Approximately 1 month later a second endoscopy was performed for removal of the polyp. The papilla of Vater was identified; 4 cm proximal to this the polyp was seen on the medial wall ofthe duodenum. A wire snare was passed around the base which was severed with a coagulating current. The

Figure 1. a, Spot film (case 1) showing a subtractive defect in the descending limb ofthe duodenum. b, Endoscopic view of umbilicated polypoid defect. c, Polypoid lesion snared at its base. d, Histologic section showing a mixed adenomatous structure.

polyp was retrieved using a grasping instrument. The patient tolerated the procedure well and was returned to her room without discomfort. Approximately 6 hours after the procedure the patient experienced severe epigastric pain associated with nausea and vomiting. She was afebrile. There was a sinus tachycardia and moderate increase in blood pressure. The abdomen was GASTROINTESTINAL ENDOSCOPY

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soft but there was marked tenderness in the epigastrium. The bowel sounds were decreased. An upright plain film of the abdomen showed a 2 mm radiolucent shadow under the right leaf of the diaphragm, suggesting free air. Serum amylase was 4500 Somogyi units; lipase was 16.3 units (normal < 1); serum calcium was normal. Nasogastric suction and intravenous fluids were begun, and the patient was pain-free in 24 hours. Treatment was continued for an additional 72 hours. A plain film ofthe abdomen 24 hours later revealed a mild ileus but no evidence offree air. Two days after the procedure serum amylase was 1125, lipase 4.1; 5 days later they were 167 and 0.6, respectively (within normal limits). The patient suffered no deterioration of her respiratory status during this episode. Pathologic examination of the polyp revealed a villous adenoma with carcinoma in situ. These slides were kindly reviewed by Dr. M.B. Dockerty of the Mayo Clinic, who concurred with this diagnosis (Figure 2b).

•O~ ..~,'!l.~ •. Q.' Figure 2. a, Radiograph (case 2) showing a suspected duodenal ulcer (white arrow) and a subtractive defect in the supra-ampullary duodenum (black arrow). b, Histologic section of papillary or villous

adenoma; at higher magnification, epithelial atypia was apparent. Vo/ume21, No.3, 1975

DISCUSSION The subject of duodenal neoplasms has been discussed elsewhere in detail.3.4 A majority of the patients in our series had asymptomatic benign lesions of the duodenum and probably derived little benefit from the polyp removal. The patient c.c., whose villous adenoma had carcinoma-insitu, is clearly an exception. A carcinoid tumor was found in patientJ.H., fortuitously, butthis was apparently notthe lesion seen on x-ray which persisted on follow-up examination. None of our patients evidenced significant postoperative bleeding. The occurrence of 1 proven episode and 1 very probable episode of aCl:Jte pancreatitis in this small series of patients may be cause for some hesitation with respect to future procedures. Both ofthese episodes involved lesions situated in the second portion of the duodenum which were endoscopically distinct and apart from the duodenal papilla. Although both patients recovered completely, pancreatitis and perforation are potentially dangerous complications. Serum amylase was not measured in the other 7 patients subjected to polypectomy. We have seen 4 patients with x-ray evidence of duodenal masses since those patients who suffered complications. In 1 patient the polyp was found in the duodenal bulb. It was pedunculated and removed easily without complication. In the other 3 patients the mass was in the second portion of the duodenum and was submucosal and broader based. In these cases, based on our previous experiences, the endoscopist decided that removal might be hazardous. Some broad indications and caveats may be drawn from our experience. The removal of a pedunculated lesion of the bulb which has some evidence of mucosal irregularity may be justified. Masses which are submucosal and appear to be covered by normal duodenal lining, particularly if they reside in the second portion of the duodenum, might best be left alone. Even if such a lesion were snared and truncated without incident, a false sense of security might arise, without justification, since there is no guarantee that the total lesion is removed in such a case. Certainly we need to know more about the effects of electrocoagulation in the duodenum. We are aware of no animal studies concerning this at present. Vennes and Silvis· have shown that simple endoscopic manipulation in the stomach and duodenum can result in hyperamylasuria. None of their patients developed symptomatic pancreatitis, and the elevations in most cases were quite modest. Cannulation of the ampulla of Vater and retrograde cholangiopancreatography have been associated with both asymptomatic serum lipase and urine amylase elevation and, less frequently, pancreatitis.8.9 In our 2 cases of pancreatitis the ampulla was identified as separate from the polyp and was only minimally manipulated. No clear pathogenetic mechanism is obvious in studying these cases. One might postulate that current leakage through the pancreas might have been large enough to initiate an inflammatory response which "peaked" several hours later. Similarly, heat transmission through the duodenal wall might have caused pancreatic damage. It has been shown that endogenous glucagon in the serum is abnormally elevated in patients with acute pancreatitis ' ° and that exogenously adm i n istered gl ucagon decreases cholecystokinin-stimulated pancreatic secretion in normal

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subjects. 11 On this basis, it has been postulated that glucagon administration might be beneficial in acute pancreatitis, although the data supporting this are still inconclusive. 12- 14 Intravenous glucagon has been useful in facilitating both endoscopic and radiographic examination of the duodenum by decreasing intestinal motility. Adverse reactions have been rare. 1S Future studies may show that glucagon has a protective

effect on the pancreas and consequently might be useful in procedures involving manipulation and electrocoagulation in the duodenum. Until the pathogenesis of postendoscopic pancreatitis is clarified and its prevention assured, one should approach electrocoagulative procedures in the duodenum with prudent trepidation.

REFERENCES

8. BLACKWOOD WD, VENNES jA, SILVIS SE: Post-endoscopy pancreatitis and hyperamylasuria. Gastrointestinal Endoscopy 20:56, 1973 9. GRIMMEL K, LIEHR H, KASPER H, KULKE H: Lipase activity in the serum after retrograde transduodenal pancreatocholangiography. Dtsch Med Wochenschr 99:43,1974 10. DAY jL, KNIGHT M, CONDON jR: The role of pancreatic glucagon in the pathogenesis of acute pancreatitis. Clin Sci 43 :603, 1973 11. KONTUREK Sj, TASLES j, OBTULOWISZ W: Characteristics of inhibition of pancreatic secretion by glucagon. Digestion 10:138,1974 12. WATERWORTH MW, BARBEZAT GO, BANK S: Glucagon in treatment of acute pancreatitis (letter). Lancet 1:1231,1974 13. CONDONjR, KNIGHT M, DAY jL: Glucagon therapy in acute pancreatitis. Brit J Surg 60:509, 1973 14. EDITORIAL: Glucagon therapy in acute pancreatitis. Brit Med J4:503, 1973 15. CHERNISH SM, MILLER RE, ROSENAK BE, SCHOLZ NE: Hypotonic duodenography with the use of glucagon. Gastroenterology 63:392, 1972

1. HAUBRICH WS, JOHNSON RB, FOROOZAN P: Endoscopic removal of a duodenal adenoma. Gastrointestinal Endoscopy 19:201, 1973 2. ALPER EI, HAUBRICH WS: Duodenoscopic removal of a Brunner's gland adenoma. Gastrointestinal Endoscopy 20:73, 1973 3. RIVER L, SILVERSTEIN j, TOPE jW: Collective review: benign neoplasms of the small intestine; critical comprehensive review, with reports of 20 cases.lnt Abstr Surg 102:1, 1956 4. CHARLES RN, KELLEY ML, CAMPETI F: Primary duodenal tumors; a study of 31 cases. Arch Int Med 111 :23, 1963 5. OSBORNE R, TOFFLER R, LOWMAN RM: Brunner's gland adenoma of the duodenum. Dig Dis 18:689,1973 6. DAGRADI A, RUlz R, ALAAMA A: Endoscopic duodenal polypectomy. Am J Gastro 61 :379-82,1974 7. ROESCH W, KOCH H, FRUHMORGEN P, CLASSEN M: Operative endoscopy ofthe upper gastrointestinal tract (abstract). Gastroenterology 64:849, 1973

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