as technological advancements have been made in endoscopy , the occurrence of duodenal tumors has increased .
but when we examine patients by endoscopy , tumors of the duodenum are not often diagnosed .
most duodenal tumors of the first portion are benign , but the incidence of malignancy increases as they are more distally located .
the main benign tumors of the duodenum are adenoma and brunner 's gland hyperplasia , but hyperplastic polyp is rare .
both malignant and benign tumors of the duodenum tend to occur in the middle or older age groups .
a polyp is defined as an abnormal growth of tissue projecting from a mucous membrane .
the prevalence of duodenal polyps is estimated to be about 1% in patients referred for esophagogastroduodenoscopy ( egd ) .
most duodenal polyps are inflammatory polyps , brunner 's gland hyperplasia and have ectopic gastric mucosa .
hyperplastic polyps usually occur in the setting of ectopic gastric mucosa and have an appearance that more closely mimics hyperplastic polyps of the gastric than the colonic type .
the clinical symptoms of duodenal tumors are abdominal pain , vomiting , melena , fever and diarrhea , and sometimes they are asymptomatic . however , there are no specific symptoms of duodenal tumors .
most duodenal polyps less than 1 cm in size do not require treatment if biopsy specimen is consistent with a benign tumor .
sessile polyps larger than 2 cm , not specifically diagnosed by biopsy specimen , are excised during the operation .
recently , capsule endoscopy ( ce ) and single- or double - balloon enteroscopy ( sbe or dbe ) have been developed and employed in clinical practice .
ce and sbe or dbe can reveal bleeding lesions or tumors in the small intestine , which could not be detected by egd and colonoscopy .
furthermore , approximately 5% of patients with gastrointestinal bleeding exhibit no identifiable source by upper endoscopy and colonoscopy .
the cause of obscure gastrointestinal bleeding ( ogib ) is usually a lesion located in the small bowel , but also includes lesions that were overlooked during conventional endoscopy . the incidence of duodenal tumors detected by ce has not been confirmed . to our knowledge ,
only 5 cases of a duodenal hyperplastic polyp detected by egd have been reported , but this is the first case of a polyp detected by ce .
, we describe the case of a lobulated and pedunculated duodenal hyperplastic polyp detected by ce and treated with polypectomy , and present a review of the literature .
a 71-year - old man was referred to our hospital in the middle of november 2009 for thorough investigation of asymptomatic iron deficiency anemia and occult blood in stools .
emergency egd revealed gastric antral vascular ectasia ( gave ) in the antrum of the stomach .
there were many coagula on gave , and these were thought to be the cause of tarry stool .
follow - up egd 1 week later revealed no bleeding lesion along with improvement of gave , and the patient was discharged .
subsequently , his hemoglobin ( hb ) level gradually decreased within 3 months ( from 9.7 to 7.9 g / dl ) , but he had no symptoms .
as the test for occult blood in stools was positive , egd and colonoscopy were performed .
meanwhile , colonoscopy revealed diverticula but no bleeding lesions . in late november 2009 , we performed ce to detect the source of occult blood in stools .
a large lobulated polyp about 2.5 cm in diameter , with a long stem , was detected in the third portion of the duodenum ( fig .
the surface of the polyp was reddish and thought to be the cause of anemia .
an air - contrast barium meal also revealed a lobulated and pedunculated polyp in the third portion of the duodenum . physical examination on admission revealed a well - developed , well - nourished man , and vital signs were normal .
laboratory examinations were as follows : hb 7.9 g / dl , serum iron concentration 44 g / dl , ferritin 57.8 ng / ml .
the polyp was 27 mm in diameter and histological examination showed an area of elongated crypts and villi with focal gastric - type surface epithelium .
epithelial nuclear atypia was present at the base of the crypts , but this feature was generally less marked at the surface ( fig .
five days after polypectomy , egd showed no bleeding , and the patient was discharged .
after treatment , his hb level improved gradually ( from 7.9 to 14.2 g / dl ) and did not decrease for 6 months .
the main benign tumors of the duodenum are adenoma and brunner 's gland hyperplasia , but hyperplastic polyps are rare .
duodenal tumors are often insidious with non - specific symptoms such as abdominal pain , anemia , and gastrointestinal bleeding .
small and non - pedunculated hyperplastic polyps are sometimes seen in the bulb of the duodenum , but large and pedunculated polyps are reportedly very rare .
the risk of development of focal adenocarcinoma in a hyperplastic polyp of the stomach is less than 1% .
similarly , the malignant potential of duodenal hyperplastic polyp is thought to be very minimal .
histological examination of those polyps following snare polypectomy shows no malignancy . in some patients with gastrointestinal tract bleeding of unknown origin , diagnosis can not be made after egd and colonoscopy . however , detection of the bleeding point recently has been enabled by the use of ce , sbe or dbe .
ce , sbe and dbe have mainly been used to investigate ogib , polyposis syndromes , crohn 's disease , and celiac disease . although ce is used mainly to investigate the jejunum and ileum , duodenal tumors are occasionally detected .
currently , epithelial gastric polyps are mainly divided into hyperplastic , adenomatous or fundic gland polyps .
focal foveolar hyperplasia and pyloric - type glandular hyperplasia have been reported , but there is some confusion in the literature concerning duodenal hyperplastic polyps .
our review of the medical literature in pubmed between 1975 and 2010 revealed 5 cases of duodenal hyperplastic polyps [ 11 , 12 , 13 , 14 , 15 ] .
the details of all 6 reported cases , including our present case , are shown in table 1 .
there were 4 males and 2 females , and their mean age was 50.5 years ( range 2 - 79 years ) .
upper gastrointestinal series was performed in 3 cases , while egd was performed in all of them .
polyps were mostly solitary , and a lobulated polyp was detected only in our case .
histology revealed a hyperplastic polyp with no atypical cells in 5 cases and a hyperplasiogenic polyp with atypical cells in 1 case .
the outcome was good with improvement of anemia in 2 cases and disappearance of the symptoms in 1 case . in our case only , the polyp , which was located in the third portion of the duodenum , was pedunculated and lobulated .
moreover , our case is the only one that underwent ce . since a duodenal hyperplastic polyp
is thought to have a minimal risk of malignancy , endoscopic treatment is effective for treatment of patients with anemia or abdominal symptoms from a duodenal polyp . in conclusion , in this report we presented the unique case of a lobulated and pedunculated hyperplastic polyp of the duodenum that was detected by ce and successfully treated with endoscopic snare polypectomy .
ce is useful in detecting the bleeding lesion when patients present with anemia and ogib undetected by egd and colonoscopy .
 we report herein the case of a lobulated and pedunculated hyperplastic polyp in the third portion of the duodenum causing anemia and occult blood in stools , which was detected by capsule endoscopy ( ce ) and treated with snare polypectomy . 
 a 71-year - old man was referred to our hospital because of anemia and occult blood in stools . 
 three months earlier , he had been admitted to another hospital because of hemorrhage from gastric antral vascular ectasia ( gave ) . despite being treated for gave , 
 hemoglobin decreased gradually . 
 esophagogastroduodenoscopy ( egd ) and colonoscopy revealed no source of bleeding . 
 however , ce revealed a polyp at the distal duodenum . 
 barium meal and egd revealed a lobulated and pedunculated polyp in the third portion of the duodenum . 
 the polyp was treated with snare polypectomy . 
 histopathological examination of the polyp revealed hyperplasia . 
 after treatment of the polyp , the anemia improved gradually . to our knowledge , there are only 6 reported cases of a duodenal hyperplastic polyp , including our case . 
 the polyp was pedunculated in only 2 cases and lobulated only in our case . 
 moreover , our case was diagnosed by ce . 
 when a patient presents with anemia or obscure gastrointestinal bleeding undiagnosed by egd and colonoscopy , ce is useful for detecting the bleeding lesion . 
Introduction
Case Report
Discussion
Disclosure Statement