Introduction: Bowel obstruction is a common gastrointestinal emergency involving an interruption of normal intraluminal content flow. Small bowel obstructions alone account for approximately 15% hospital admissions in the United States. A rare, but lethal cause of mechanical obstructions are small bowel tumors. This paper reveals a rare case of mechanical obstruction secondary to a periampullary duodenal tubulovillous adenoma.
Case Description/Methods: Our patient is an 88-year-old Hispanic male with a past medical history of prostate cancer and long segment Barrett’s esophagus who presented to the emergency department with coffee ground emesis 5 days prior to admission with associated epigastric abdominal pain. The patient was unable to tolerate any oral intake including liquids since the onset of symptoms. He denied NSAID or anticoagulant use.
The esophagus and stomach were found to be dilated and filled with fluid. Given these findings, the patient was deemed to be a high risk for aspiration and underwent an emergent esophagogastroduodenoscopy (EGD). During the procedure, a large frondlike/villous mass was found within the third portion of the duodenum. This mass encompassed nearly 75% of the lumen of the duodenum. Biopsies were taken and the pathology revealed a tubulovillous adenoma with foci of high-grade dysplasia (figure 2). The results were discussed with the patient with several treatment options, including surgical intervention for treatment or symptomatic management were discussed with the patient and his family. The patient was against surgical intervention and requested time to discuss the results with his family.
Discussion: Duodenal adenomas have an overall incidence of 0.4% of the lesions found during upper endoscopic studies. Furthermore, tubulovillous tumors of the duodenum are extremely rare, accounting for less than one percent of all duodenal neoplasms. The presence of duodenal adenomas is seen in up to 90% of patients with FAP, most commonly in the ampulla, periampullary regions, or distal duodenum. This adds to the uniqueness of our case, as our patient had no prior history of FAP. Although most of these patients are asymptomatic, they may occasionally display symptoms such as abdominal pain, melena, or weight loss. In addition, these tumors can also cause complications such as pancreatitis, duodenal obstructions or intussusception.
