Does a diagnosis of bile reflux gastritis with a polypoid lesion in the duodenal bulb, potentially indicating Brunner's glands hyperplasia or gastric heterotopia, warrant Endoscopic Gastric Fundoplication?

Management of Bile Reflux Gastritis with Duodenal Bulb Lesion

Endoscopic Gastric Fundoplication is not indicated for bile reflux gastritis with a polypoid lesion in the duodenal bulb that may represent Brunner's gland hyperplasia or gastric heterotopia. 1

Understanding the Findings

• Non-neoplastic lesions in the duodenal bulb, such as gastric heterotopia and Brunner's gland hyperplasia, are common findings and typically do not require intervention unless symptomatic 1
• Brunner's gland hyperplasia represents a benign proliferation of normal duodenal Brunner's glands, which may appear as solitary pedunculated lesions up to 2-5 cm in size 1
• Bile reflux gastritis is characterized by free enterogastric reflux of bile causing abdominal pain, bilious vomiting, and weight loss 2

Management Approach for Duodenal Lesions

For Brunner's Gland Hyperplasia:

• Resection is generally unnecessary unless the lesion is:

  • Symptomatic (causing obstruction, pain, or bleeding)
  • Large (>2 cm)
  • Showing concerning features requiring histological confirmation 1

• Endoscopic management options for symptomatic lesions include:

  • Endoscopic mucosal resection (EMR) for lesions with good endoscopic maneuverability and no muscular layer involvement 3
  • Hot snare polypectomy for smaller lesions 4

For Gastric Heterotopia:

• These non-neoplastic lesions in the duodenal bulb do not require endoscopic resection unless they are symptomatic or bleeding 1
• Careful optical evaluation and pathologic inspection are recommended to differentiate from neoplastic lesions 1

Management Approach for Bile Reflux Gastritis

• Medical management with prokinetic agents or bile acid sequestrants is the first-line approach, though results are often disappointing 2
• For persistent symptoms despite medical management, surgical diversion of bile away from gastric mucosa (Roux-en-Y diversion) is considered the treatment of choice 2
• Endoscopic Gastric Fundoplication is not indicated for bile reflux gastritis and is not mentioned in any guidelines as a treatment option 1, 2

Recommended Next Steps

• Obtain histopathological confirmation of the duodenal bulb lesion to determine if it is Brunner's gland hyperplasia or gastric heterotopia 1
• Document the presence, number, size, location, and morphology of the duodenal lesion 1
• For non-neoplastic lesions without symptoms, no intervention is required 1
• For bile reflux gastritis:
  • Trial medical management with prokinetics and bile acid sequestrants 2
  • Consider surgical consultation for Roux-en-Y diversion if symptoms persist despite medical management 2

Important Considerations and Pitfalls

• Duodenal lesions may mimic malignancy, so extensive pre-operative evaluation including adequate biopsies is necessary to avoid unnecessary radical surgical procedures 5
• Endoscopic ultrasound may be helpful to evaluate the base of the lesion and internal characteristics before deciding on management approach 3
• Rare cases of dysplasia in Brunner's gland hyperplasia have been reported, so histological confirmation is important 1
• The risk of post-procedural bleeding after duodenal lesion resection is higher than elsewhere in the GI tract, with risk proportional to lesion size 1