A Preponderance of Polyps: Sequelae of Familial Adenomatous Polyposis

A man in his fourth decade with familial adenomatous polyposis (FAP) and previous colectomy due to colon adenocarcinoma underwent esophagogastroduodenoscopy (EGD) to investigate 3 days of nausea, epigastric abdominal pain, and coffee ground emesis; no source of bleeding was found. During the endoscopy, patchy mucosal abnormalities throughout the duodenum were identified and biopsied (Figure 1). The abnormalities raised concern for duodenal polyposis. The polyps were innumerable and coalescent in appearance (Figure 2). Histology showed tubulovillous adenomas with low-grade dysplasia. According to Spigelman’s classification, the patient had numerous circumferential (>20; 3 points), large (>10 mm; 3 points), and tubulovillous (2 points) duodenal polyposis with low-grade dysplasia (1 point).1 The 9-point score corresponded to stage IV duodenal polyposis. He was discharged with plans for outpatient endoscopic ultrasound (EUS) of the duodenal polyposis; however, a few weeks later, he presented again with nausea and vomiting, and was admitted due to concerns for partial small bowel obstruction. Radial EUS evaluation of these circumferential duodenal polyps revealed mucosal involvement without deeper invasion. Nodes sampled during EUS were adenocarcinoma with histologic appearance similar to his former colorectal adenocarcinoma, suggesting a metastatic etiology, not a new primary duodenal cancer. Due to the complicated hospital course and the extent of his metastatic disease, the patient opted for palliative care and passed away shortly thereafter.