From the Guidelines
Duodenal mucosa with foveolar metaplasia does not require endoscopic resection unless it is symptomatic or bleeding, as it is considered a non-neoplastic lesion that may mimic neoplastic adenomatous pathology 1.
Clinical Considerations
When encountering duodenal mucosa with foveolar metaplasia, it is crucial to distinguish it from neoplastic lesions through careful optical evaluation and pathologic correlation to exclude dysplasia. The presence of foveolar metaplasia itself is not an indication for endoscopic intervention unless accompanied by symptoms or active bleeding.
Management Approach
- Treatment of the underlying cause is the primary approach, which may involve addressing chronic inflammation, H. pylori infection if present, or the effects of long-term proton pump inhibitor (PPI) use.
- Endoscopic surveillance is not routinely recommended for foveolar metaplasia unless other concerning features are present, emphasizing the importance of a thorough initial evaluation.
- Colonoscopy should be considered if a high-quality examination has not been performed in the last 3 years, given the potential for concomitant colonic adenomas, although this is more directly relevant to patients with duodenal adenomas.
Key Considerations for Clinical Practice
- The approach to managing duodenal lesions, including those with foveolar metaplasia, should prioritize careful evaluation and individualized treatment planning, considering the lesion's characteristics, patient comorbidities, and the potential risks and benefits of intervention 1.
- Best practice advice from recent guidelines emphasizes the importance of detailed lesion description, including size, morphology, and location, to facilitate appropriate therapeutic planning and subsequent surveillance.
From the Research
Duodenal Mucosa with Foveolar Metaplasia
- Foveolar gastric metaplasia of the duodenum is a frequent but not as yet considered correlate of endoscopically detected duodenal polyps 2, 3.
- The majority of foveolar gastric metaplasias associated with polyps presented a typical benign endoscopic appearance and they were diagnosed by biopsy 3.
- Foveolar gastric metaplasia can present as a duodenal tumor with an atypical appearance, and both endoscopic ultrasonography and narrow band imaging are useful techniques to increase the diagnostic rate of this condition 2.
Association with Helicobacter pylori
- Helicobacter pylori colonisation of duodenal foveolar metaplasia requires concurrent gastric infection 4.
- There is no evidence of an etiologic role for Helicobacter pylori in gastric foveolar metaplasia and gastric heterotopia in the duodenum 5.
- However, H. pylori infection is related to the extent of gastric metaplasia in the duodenum, and eradication of H. pylori can lead to significant decrease and complete regression of gastric metaplasia 6.
Clinical Characteristics
- Foveolar gastric metaplasia is a frequent, so far neglected type of duodenal polyp, with a similar distribution of age ranges and a dominance of male sex 3.
- The endoscopic findings of foveolar gastric metaplasia can include redness of the mucosa, erosion/ulcer, and loss of mucosal folds, as well as a polypoid appearance 2, 3.
- Gastric heterotopia is likely a congenital lesion, and its association with fundic gland polyps suggests that use of proton pump inhibitors may enhance its endoscopic detection 5.