1193 Biopsy of the Papilla in Patients With Familial Adenomatous Polyposis (FAP): Risks, Benefits, and Changes in Management

Abstract

INTRODUCTION: Nearly all patients with FAP will develop duodenal adenomas. Ampullary/duodenal cancer is the leading cause of death in patients with FAP after colectomy. Risk of duodenal cancer can be predicted by the Spigelman staging system. Guidelines recommend upper endoscopic surveillance with forward and side-viewing scopes to evaluate the duodenum and visualize the papilla. There is no consensus whether the papilla should be routinely biopsied or included in Spigelman staging. Some endoscopists refrain from biopsy of the papilla due to a theoretical risk of pancreatitis. No data is available to support this risk. We aim to identify the incidence of pancreatitis after biopsy of the papilla in FAP patients and the effect of biopsy on Spigelman stage. METHODS: This retrospective cohort study identified consecutive FAP patients at the Cleveland Clinic between 1/2011-12/2018. FAP patients with ≥1 endoscopy with biopsy of the duodenal papilla were included. Patients with history of foregut surgery were excluded. Medical records determined demographics, endoscopic data, and Spigelman staging with/without biopsy. Post-procedural pancreatitis was defined as 2/3 of typical symptoms, lipase 3 times upper limit of normal, or radiography consistent with pancreatitis within 7 days of esophagogastroduodenoscopy (EGD). RESULTS: 273 FAP patients (52.4% male) with 792 EGDs with biopsy of the papilla were identified (Table 1). Cumulative times that the papilla was biopsied over the study period ranged from 1-8/patient. 2 patients developed pancreatitis. Of all EGDs with ampullary biopsy, 0.34% (3/792) developed post-procedural pancreatitis. The papilla appeared normal in 546/792 exams and 1 patient developed pancreatitis with biopsy of normal papilla. This patient was admitted for 4 days with mild acute pancreatitis (BISAP 1). The papilla was abnormal in 226 exams and 2 episodes of pancreatitis occurred in the same patient. This patient had a history of chronic pancreatitis due to alcohol abuse. Hospitalization wasn’t necessary for mild acute pancreatitis (BISAP 1). Biopsy of normal papilla increased Spigelman stage in 15 patients, one upstaged from Spigelman III to IV and had a pancreas-sparing duodenectomy. CONCLUSION: Pancreatitis after biopsy of the duodenal papilla is rare, especially in patients without a history of pancreatitis. Biopsy of normal papilla in FAP changes patient management. Physicians managing FAP should understand risks/benefits of biopsy of the papilla and include it in Spigelman staging.