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Retroflexion in the duodenum for evaluation of duodenal bulb lesions
Retroflexion in the duodenum for evaluation of duodenal bulb lesions Lawrence J. Brandt, MD, MACG, Amnon Gotian, MD
Retroflexion is a safe and useful maneuver in the stomach and rectum.1-4 This is a description of the first use of this maneuver in the duodenal bulb for the diagnosis and treatment of eccentric juxtapyloric masses of gastric heterotopia with foci of adenoma in 2 patients. CASE REPORTS Case 1 A 76-year-old woman was referred for management of a duodenal polyp discovered during an evaluation for epigastric pain. Only the edge of the lesion could be seen endoscopically, and the referring gastroenterologist was considering operative removal. Her medical history was significant for diabetes mellitus, hypertension, and coronary artery bypass graft surgery. Medications included glyburide, acarbose, amlodipine, and omeprazole. Examination was unremarkable. By using an upper endoscope with an insertion tube diameter of 8.9 mm (EG 2731, Pentax, Orangeburg, N.Y.), EGD was performed after premedication with intravenously administered midazolam and meperidine. Only one edge of the lesion was apparent on entering the duodenal bulb (Fig. 1). Retroflexion of the endoscope within the bulb revealed a 2.0- to 2.5-cm diameter flat polypoid mass with studding of the pyloric circumference by tiny satellite lesions of similar appearance. Multiple biopsy specimens revealed gastric heterotopia with fundic glands and chronic inflammation. Because of the unusual nature of the lesion, the patient underwent EGD 1 month later during which most of the lesion was removed by electrosurgical snare excision with the endoscope tip retroflexed in the bulb (Fig. 2). Histopathologic evaluation of the resected lesion again revealed gastric heterotopia, but with focal adenomatous change. Because of the foci of adenoma, the remnant polyp was removed 2 weeks later by electrosurgical snare polypectomy, again with the endoscope retroflexed in the bulb; all satellite lesions were photoablated with a Nd:YAG laser (98 pulses, total 3733 J) because of their gross similarity to the parent lesion and the inability to effectively sample all of them (Fig. 3). The patient tolerated all procedures well and 6 months later she was asymptomatic and taking no medications.
From the Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. Reprint requests: Lawrence J. Brandt, MD, MACG, Chief, Division of Gastroenterology, Montefiore Medical Center, 111 East 210th St., Bronx, NY 10467. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/54/120883 doi:10.1067/mge.2002.120883 438 GASTROINTESTINAL ENDOSCOPY
Figure 1. Conventional forward endoscopic view of duodenal bulb revealing one edge of lesion (Case 1).
Figure 2. Retroflexed endoscopic view in duodenum showing entire lesion during snare polypectomy (Case 1).
Figure 3. Retroflexed endoscopic view of duodenum after laser photoablation of satellite lesions (Case 1).
VOLUME 55, NO. 3, 2002
Retroflexion in the duodenum
L Brandt, A Gotian
Case 2 A 47-year-old woman was referred for management of a duodenal polyp discovered during an evaluation for epigastric pain. A pyramidal-shaped, broad-based polyp in the duodenal bulb was described by the referring gastroenterologist who was unable to remove it with a standard forward view and a polypectomy snare. Biopsy specimens revealed a tubulovillous adenoma, and operative removal was being considered. Medical history was significant for hypertension, hypothyroidism, chronic obstructive pulmonary disease, and oophorectomy. Medications included L-thyroxine, valsartan, and diltiazem. Examination was unremarkable. EGD with an 8.9-mm diameter upper endoscope (EG 2731, Pentax), was performed with the patient under premedication with midazolam and meperidine. Only part of the lesion was apparent on entering the duodenal bulb. Retroflexion of the endoscope within the bulb revealed 2 polyps, each approximately 0.6 × 0.5 × 0.4 cm in diameter, with some satellite studding of adjacent mucosa by similarappearing tissue (Fig. 4). Both polyps were removed by electrosurgical snare polypectomy with the endoscope retroflexed (Fig. 5). Histopathologic evaluation revealed one tubular adenoma with focal villous features and one gastric-type hyperplastic polyp with a focal area of adenomatous change; the satellites were villous adenomas. Endoscopy with duodenal retroflexion 2 weeks later revealed no residual lesions, but there was persistent irregularity of the duodenal juxtapyloric mucosa because of the satellite lesions (Fig. 6). With the endoscope retroflexed in the bulb the satellite lesions were photoablated with an Nd:YAG laser (50 pulses, total 2851 J). The patient tolerated all procedures well. Nine months after polypectomy and laser therapy, the patient continued to have epigastric pain; she is taking omeprazole orally, 20 mg, twice daily.
DISCUSSION Retroflexion is a commonly performed maneuver in the endoscopic evaluation of the stomach and anorectum.1-4 In addition, the senior author (L.J.B.) has safely used the U-turn maneuver on more than 50 occasions in the cecum (unpublished data); in one case a 1-cm diameter polyp, not seen on prograde inspection, was discovered and removed. Retroflexion is also valuable in the duodenal bulb for the diagnosis and treatment of lesions not well visualized by the conventional forward viewing method. Retroflexion with a forwardviewing instrument is an alternative to visualization with a side-viewing instrument. An 8.9-mm diameter endoscope was used in both of the present cases. However, a smaller-diameter endoscope would likely facilitate the retroflexion in the bulb. No technical difficulties were encountered during retroflexion in the duodenal bulb (e.g., rupture, endoscope entrapment). Common sense, however, dictates that this maneuver should be avoided in patients VOLUME 55, NO. 3, 2002
Figure 4. Retroflexed endoscopic view of duodenum showing 1 of 2 polyps present (Case 2).
Figure 5. Retroflexed endoscopic view of duodenum showing polyp (Fig. 4) being removed (Case 2).
Figure 6. Retroflexed endoscopic view of duodenum 2 weeks after polyp removal (Case 2).
GASTROINTESTINAL ENDOSCOPY 439
with chronic peptic ulcer disease and severe duodenal scarring. Its use in acute ulcer disease (e.g., to endoscopically treat a bleeding vessel not approachable on forward view) is unstudied, but appears attractive to us. Retroflexion allows circumferential inspection of the duodenal bulb and juxtapyloric region as well as treatment of lesions in this area. As such it may be an important adjunct to conventional duodenoscopy, but formal studies are needed to assess the risk-benefit ratio of this maneuver before it can be recommended for general use.
440 GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Burke EL, Chappelka AR Jr, Levine SM. Examination of the esophago-gastric junction area and fundus by retroflexion of the flexible-tip gastroscope: an analysis of 100 consecutive attempts. Gastrointest Endosc 1970;16:130-4. 2. Schachter H, Kobayashi S. The gastroscopic retroflexion method in the diagnosis of sliding esophageal hiatus hernia. Gastrointest Endosc 1970;17:78-80. 3. Cutler AF, Pop A. Fifteen years later: colonoscopic retroflexion revisited. Am J Gastroenterol 1999;94:1537-8. 4. Grobe JL, Kozarek RA, Sanowski RA. Colonoscopic retroflexion in the evaluation of rectal disease. Am J Gastroenterol 1982;77:856-8.
VOLUME 55, NO. 3, 2002
Retroflexion is a safe and useful maneuver in the stomach and rectum.1-4 This is a description of the first use of this maneuver in the duodenal bulb for the diagnosis and treatment of eccentric juxtapyloric masses of gastric heterotopia with foci of adenoma in 2 patients. CASE REPORTS Case 1 A 76-year-old woman was referred for management of a duodenal polyp discovered during an evaluation for epigastric pain. Only the edge of the lesion could be seen endoscopically, and the referring gastroenterologist was considering operative removal. Her medical history was significant for diabetes mellitus, hypertension, and coronary artery bypass graft surgery. Medications included glyburide, acarbose, amlodipine, and omeprazole. Examination was unremarkable. By using an upper endoscope with an insertion tube diameter of 8.9 mm (EG 2731, Pentax, Orangeburg, N.Y.), EGD was performed after premedication with intravenously administered midazolam and meperidine. Only one edge of the lesion was apparent on entering the duodenal bulb (Fig. 1). Retroflexion of the endoscope within the bulb revealed a 2.0- to 2.5-cm diameter flat polypoid mass with studding of the pyloric circumference by tiny satellite lesions of similar appearance. Multiple biopsy specimens revealed gastric heterotopia with fundic glands and chronic inflammation. Because of the unusual nature of the lesion, the patient underwent EGD 1 month later during which most of the lesion was removed by electrosurgical snare excision with the endoscope tip retroflexed in the bulb (Fig. 2). Histopathologic evaluation of the resected lesion again revealed gastric heterotopia, but with focal adenomatous change. Because of the foci of adenoma, the remnant polyp was removed 2 weeks later by electrosurgical snare polypectomy, again with the endoscope retroflexed in the bulb; all satellite lesions were photoablated with a Nd:YAG laser (98 pulses, total 3733 J) because of their gross similarity to the parent lesion and the inability to effectively sample all of them (Fig. 3). The patient tolerated all procedures well and 6 months later she was asymptomatic and taking no medications.
From the Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. Reprint requests: Lawrence J. Brandt, MD, MACG, Chief, Division of Gastroenterology, Montefiore Medical Center, 111 East 210th St., Bronx, NY 10467. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/54/120883 doi:10.1067/mge.2002.120883 438 GASTROINTESTINAL ENDOSCOPY
Figure 1. Conventional forward endoscopic view of duodenal bulb revealing one edge of lesion (Case 1).
Figure 2. Retroflexed endoscopic view in duodenum showing entire lesion during snare polypectomy (Case 1).
Figure 3. Retroflexed endoscopic view of duodenum after laser photoablation of satellite lesions (Case 1).
VOLUME 55, NO. 3, 2002
Retroflexion in the duodenum
L Brandt, A Gotian
Case 2 A 47-year-old woman was referred for management of a duodenal polyp discovered during an evaluation for epigastric pain. A pyramidal-shaped, broad-based polyp in the duodenal bulb was described by the referring gastroenterologist who was unable to remove it with a standard forward view and a polypectomy snare. Biopsy specimens revealed a tubulovillous adenoma, and operative removal was being considered. Medical history was significant for hypertension, hypothyroidism, chronic obstructive pulmonary disease, and oophorectomy. Medications included L-thyroxine, valsartan, and diltiazem. Examination was unremarkable. EGD with an 8.9-mm diameter upper endoscope (EG 2731, Pentax), was performed with the patient under premedication with midazolam and meperidine. Only part of the lesion was apparent on entering the duodenal bulb. Retroflexion of the endoscope within the bulb revealed 2 polyps, each approximately 0.6 × 0.5 × 0.4 cm in diameter, with some satellite studding of adjacent mucosa by similarappearing tissue (Fig. 4). Both polyps were removed by electrosurgical snare polypectomy with the endoscope retroflexed (Fig. 5). Histopathologic evaluation revealed one tubular adenoma with focal villous features and one gastric-type hyperplastic polyp with a focal area of adenomatous change; the satellites were villous adenomas. Endoscopy with duodenal retroflexion 2 weeks later revealed no residual lesions, but there was persistent irregularity of the duodenal juxtapyloric mucosa because of the satellite lesions (Fig. 6). With the endoscope retroflexed in the bulb the satellite lesions were photoablated with an Nd:YAG laser (50 pulses, total 2851 J). The patient tolerated all procedures well. Nine months after polypectomy and laser therapy, the patient continued to have epigastric pain; she is taking omeprazole orally, 20 mg, twice daily.
DISCUSSION Retroflexion is a commonly performed maneuver in the endoscopic evaluation of the stomach and anorectum.1-4 In addition, the senior author (L.J.B.) has safely used the U-turn maneuver on more than 50 occasions in the cecum (unpublished data); in one case a 1-cm diameter polyp, not seen on prograde inspection, was discovered and removed. Retroflexion is also valuable in the duodenal bulb for the diagnosis and treatment of lesions not well visualized by the conventional forward viewing method. Retroflexion with a forwardviewing instrument is an alternative to visualization with a side-viewing instrument. An 8.9-mm diameter endoscope was used in both of the present cases. However, a smaller-diameter endoscope would likely facilitate the retroflexion in the bulb. No technical difficulties were encountered during retroflexion in the duodenal bulb (e.g., rupture, endoscope entrapment). Common sense, however, dictates that this maneuver should be avoided in patients VOLUME 55, NO. 3, 2002
Figure 4. Retroflexed endoscopic view of duodenum showing 1 of 2 polyps present (Case 2).
Figure 5. Retroflexed endoscopic view of duodenum showing polyp (Fig. 4) being removed (Case 2).
Figure 6. Retroflexed endoscopic view of duodenum 2 weeks after polyp removal (Case 2).
GASTROINTESTINAL ENDOSCOPY 439
with chronic peptic ulcer disease and severe duodenal scarring. Its use in acute ulcer disease (e.g., to endoscopically treat a bleeding vessel not approachable on forward view) is unstudied, but appears attractive to us. Retroflexion allows circumferential inspection of the duodenal bulb and juxtapyloric region as well as treatment of lesions in this area. As such it may be an important adjunct to conventional duodenoscopy, but formal studies are needed to assess the risk-benefit ratio of this maneuver before it can be recommended for general use.
440 GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Burke EL, Chappelka AR Jr, Levine SM. Examination of the esophago-gastric junction area and fundus by retroflexion of the flexible-tip gastroscope: an analysis of 100 consecutive attempts. Gastrointest Endosc 1970;16:130-4. 2. Schachter H, Kobayashi S. The gastroscopic retroflexion method in the diagnosis of sliding esophageal hiatus hernia. Gastrointest Endosc 1970;17:78-80. 3. Cutler AF, Pop A. Fifteen years later: colonoscopic retroflexion revisited. Am J Gastroenterol 1999;94:1537-8. 4. Grobe JL, Kozarek RA, Sanowski RA. Colonoscopic retroflexion in the evaluation of rectal disease. Am J Gastroenterol 1982;77:856-8.
VOLUME 55, NO. 3, 2002