Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
(Usually asymptomatic) May present with vague abdominal pain, bleeding (hematemesis or melena), or iron deficiency anemia (if bleeding is chronic).
History of Present Illness:
Presence and character of any abdominal pain (location, timing, severity).
History of gastrointestinal bleeding (hematemesis – vomiting blood, melena – black tarry stools).
Passage of blood in the stool (bright red blood is more concerning for lower gastrointestinal bleeding).
Symptoms of anemia (fatigue, shortness of breath, pale skin).
Risk factors for duodenal adenomas (e.g., age over 50, family history of polyposis syndromes, Barrett’s esophagus).
Prior upper endoscopy findings (if any).
Past Medical History:
Underlying medical conditions (e.g., peptic ulcer disease, gastroesophageal reflux disease (GERD)).
Prior abdominal surgeries (may increase risk of peptic ulcer disease).
Smoking history (smoking is a risk factor for peptic ulcer disease).
Social History:
Alcohol consumption habits (excessive alcohol intake can irritate the duodenum).
Nonsteroidal anti-inflammatory drug (NSAID) use (NSAIDs can increase risk of peptic ulcer disease).
Family History:
First-degree relative with peptic ulcer disease, familial adenomatous polyposis (FAP), or Gardner syndrome (hereditary syndromes increasing risk of duodenal adenomas).
Physical Exam:
General examination: Assess for signs of anemia (pale skin, conjunctival pallor).
Abdominal examination: Palpate for abdominal tenderness or masses.
Laboratory Tests:
Complete blood count (CBC): May show microcytic anemia (iron deficiency) if bleeding is present.
Stool occult blood test: May be positive if there is recent gastrointestinal bleeding.
Serum iron studies: May show low iron levels if chronic bleeding is present.
Imaging Studies:
Upper endoscopy with biopsy: The gold standard for diagnosis.
Endoscopy allows visualization of the upper gastrointestinal tract
(esophagus, stomach, duodenum) and biopsy of suspicious lesions.
(Imaging not typically used for initial diagnosis but may be considered
in certain cases):
Abdominal CT scan (rare): May be used if there is concern for
perforation or other complications.
Pathology:
Histopathological examination of the biopsy specimen is crucial to confirm the diagnosis of a non-ampullary duodenal adenoma and determine its grade (low-grade or high-grade).
Assessment:
Non-ampullary duodenal adenoma: Confirmed by upper endoscopy with biopsy showing adenomatous tissue.
Size and location of the adenoma: Impacts treatment decisions.
Grade of dysplasia: Low-grade adenomas have lower malignant potential than high-grade adenomas.
Presence of symptoms (bleeding, anemia): May influence urgency of treatment.
Differential Diagnoses:
Consider other causes of upper gastrointestinal bleeding or peptic ulcer symptoms:
Peptic ulcer disease
Esophagitis
Gastritis
Plan:
The treatment plan depends on the size, location, and grade of the adenoma. Possible elements include:
Endoscopic resection (preferred): Removal of the adenoma during the initial endoscopy using techniques like endoscopic mucosal resection (EMR) or hot biopsy.
Surgical resection (if endoscopic resection is not feasible):
Removal of a portion of the duodenum with the adenoma. This is usually reserved for large or difficult-to-reach adenomas.
Surveillance: Regular follow-up endoscopies to monitor for recurrence
(especially for high-grade adenomas).
Lifestyle modifications: Smoking cessation and limiting NSAID use may help prevent recurrence.
Prognosis:
The prognosis depends on the grade of the adenoma. Low-grade adenomas have a low risk of progressing to cancer