2567 A Rare Manifestation of a Bleeding Tubulovillous Duodenal Polyp Presenting as an Upper Gastrointestinal Hemorrhage

Abstract

INTRODUCTION: Duodenal polyps are rare findings, they have been reported in only 0.3-1.5% of individuals who undergo upper endoscopy (EGD). They are histologically classified by mucin phenotype into intestinal (89.1%), morphologically tubular or tubulovillous adenomas, and gastric type (10.9%); grossly as sessile or pedunculated polyps, nodules, excrescences. They can be located either in the duodenal bulb, ampullary region, or distal duodenum. Duodenal polyps carry a low probability for malignant transformation, around 90% are non-neoplastic. We present a case of a 76-yr-old male who presented with hematemesis, an atypical and unusual manifestation. CASE DESCRIPTION/METHODS: A 76-year-old male presented for feeling “off” and increased respiratory secretions. Gastroenterology was consulted following an episode of coffee-ground hematemesis which was noticed while checking residuals after tube feeding. The patient's hemoglobin was 9.9 g/dL and he was hemodynamically stable thus EGD was not done. His hematemesis was thought to be secondary to apixaban and aspirin so both were stopped. However, his hemoglobin decreased to 6.6 g/dL and orogastric lavage revealed 1 liter of coffee-ground emesis. Subsequently, the patient underwent an emergent EGD which revealed a 10 mm pedunculated polyp in the proximal duodenum with active bleeding. The polyp was resected with hot snare and clipped twice with a resolution of bleeding and stabilization of his hemoglobin. The biopsy of the polyp tissue revealed a pedunculated, intestinal-type tubulovillous adenoma with minute foci of high-grade dysplasia (HGD). DISCUSSION: The isolated occurrence of such adenomas is rare and presentation as an upper gastrointestinal hemorrhage is even rarer. Our patient presented with a malignant subtype although around 90% are benign. His neoplastic pedunculated polyp was identified in the second portion of the duodenum, which is another atypical occurrence. His polyp was 10 mm, but with HGD, the odds of being malignant are higher as was seen on biopsy. There are currently no definitive guidelines on how a duodenal polyp should be resected; further studies are needed to assess techniques that can decrease mortality and prevent a recurrence. EGD techniques that are currently used include endoscopic snare and electrocautery, which was successful in this case. EGD surveillance within 1-6 months is recommended due to an increased risk of colorectal neoplasia. It is also important for practitioners to keep in mind rarer causes of upper GI bleeding.