GI Endoscopy · 7 min read
Duodenal Adenomas: Ampullary Is Papillectomy, Non-Ampullary Is EMR on a Thin Wall
Location decides the tool. Papilla means ERCP skill. D1 or D2 off the papilla means lift-and-snare on a wall that perforates easily.
Clinical Bottom Line
| Lesion | Practical plan |
|---|---|
| Non-ampullary duodenal adenoma | Off the papilla in D1 or D2. EMR is first-line in ESGE 2021. Thin wall, delayed bleed, consider clip closure. |
| Ampullary adenoma | Involves the major papilla. Side-viewing duodenoscope, endoscopic papillectomy, prophylactic pancreatic stent in most cases. Not a forward-view snare. |
| FAP / polyposis | Different surveillance density. Spigelman staging. Do not treat a carpet as a sporadic 8 mm adenoma. |
| Subepithelial / lipoma / Brunner | Not an adenoma. EUS if the pit pattern is wrong or the lesion is submucosal. Do not EMR a lipoma "to be sure." |
How do I tell ampullary from not?
Look at the os. If the lesion involves the papillary orifice, or you cannot find the os because the lesion is sitting on it, it is ampullary until a duodenoscope says otherwise. Biopsy gently if you must, knowing that inflammation will muddy dysplasia grade. Photograph the relationship to the papilla on white light before anyone injects.
Non-ampullary sporadic adenomas are usually D2, sessile or flat, and easy to underestimate because the folds hide the edge. They are also easy to overcall: Brunner gland hyperplasia, gastric heterotopia in the bulb, and regenerative mucosa after NSAID injury all mimic adenomas. If pit pattern and NBI are not adenomatous, think twice before you book EMR.
What does ESGE want for non-ampullary lesions?
Vanbiervliet 2021 (PMID 33822331) is the ESGE guideline on superficial nonampullary duodenal tumors. EMR is the resection tool for most visible adenomas. ESD is not the default in the duodenum; perforation risk is higher than in the stomach or colon. Recurrence after EMR is real and is why you photograph the scar and look again.
The duodenal wall lacks a thick colon-like safety cushion. Delayed bleed and delayed perforation are the complications that show up after a clean-looking room. Carbon dioxide. Admit when the bed is large. Clip when the defect will close without tearing. ESGE says the clip data are limited and case-by-case. A colon-style zipper on a 40 mm duodenal bed is how you convert a bleed into a hole.
Underwater EMR is a reasonable capture trick on a floppy fold, same idea as in the colon. That does not make the wall thicker. UEMR page is colonic. Do not paste those numbers onto D2.
What about the papilla?
Endoscopic papillectomy is an ERCP procedure. Staging (EUS or MRCP when you need to know about intraductal growth), a side-viewer, snare resection, and a pancreatic stent to lower pancreatitis risk. Bleeding is common enough that you should already have a thermal and clip plan. This page will not pretend to be a papillectomy atlas. If the lesion is ampullary and papillectomy is not on your list, refer. TTS and cap-clip salvage for a hole: TTS and Padlock vs OTSC.
Selected references
Last reviewed September 20, 2026. Written for clinicians who found a duodenal polyp on forward-viewing endoscopy and now have to name it and refer it.
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