S4766 Gastric Intestinal Metaplasia of Duodenum With Subsequent Development of Duodenal Adenoma: An Opportunity for Endoscopic Vigilance

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Introduction: Sporadic non-ampullary duodenal adenomas are detected in patients without familial adenomatous polyposis syndrome with increasing endoscopic visualization. However, progression from duodenal gastric metaplasia remains exceedingly rare with literature reviews suggesting few case reports. Case Description/Methods: A 49-year-old woman presented with epigastric pain with reported improvement after meals. An esophagogastroduodenoscopy for duodenal ulcer evaluation was recommended. Patient had a prior history of chronic gastroesophageal reflux disease with short segment Barrett's without dysplasia diagnosed since 2012, IBS-D and chronic anal fissure. A 5 mm non ampullary lesion was seen in the second portion of duodenum- pathology revealed tubular adenoma with focal high-grade dysplasia, random stomach biopsies were negative for H. pylori. She underwent endoscopic cold snare excision of 5 to 6 mm sessile polyp subsequently on a therapeutic esophagogastroduodenoscopy with pathology demonstrating high grade dysplasia arising in tubular adenoma (Figure 1A (1, 2)). Prior review of endoscopic evaluations revealed that the patient had undergone an esophagogastroduodenoscopy about a year before this presentation for workup of diarrhea, celiac disease and IBS-D. Pathology at that time had showed reactive duodenopathy, duodenal mucosa with gastric mucin metaplasia, Brunner's gland hyperplasia and nonspecific chronic inflammation. There was no dysplasia, acute inflammation, granulomas or villous blunting. Discussion: Gastric metaplasia of duodenum is most often described in context of H. pylori associated gastritis or nonsteroidal anti-inflammatory drug use. Progression to duodenal adenoma is rare with most cases of duodenal gastric metaplasia suggesting endoscopic mucosal defects, inflammation, scar. There remains paucity of surveillance and treatment guidelines for this entity in the absence of H. pylori. The present case highlights the necessity of endoscopic vigilance in patients with gastric metaplasia of duodenum. Given established transformation risk to adenocarcinoma and duodenal adenomas, resection with cold snare or endoscopic mucosal resection, remains recommended for non- ampullary duodenal lesions. However, there are no current guidelines for subsequent endoscopic surveillance gastric metaplasia of duodenum.Figure 1.: A) Endoscopic cold snare excision of duodenal adenoma. B) L: tubular adenoma with focal high-grade dysplasia. R: reactive duodenopathy, duodenal mucosa with gastric mucin metaplasia, Brunner's gland hyperplasia.

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