Post written by Ahmed Akhter, MD, Eric M. Nelsen, MD, and Deepak V. Gopal, MD, FRCP(C), FASGE, from the Division of Gastroenterology and Hepatology, University of Wisconsin, Madison, Wisconsin.

In our video, an elderly male with several comorbidities including chronic kidney disease and type-2 diabetes mellitus presented with a 2 day history of melena. He underwent an upper endoscopy which demonstrated a 2-3 cm ampullary mass with initial pinch biopsies negative for malignancy. Subsequent endoscopic ultrasound demonstrated a 2.1 x 1.1 cm mass without invasion into the muscularis propria. Core biopsy specimens revealed a neuroendocrine (carcinoid tumor). The patient was referred to surgery; however, he declined and endoscopic removal was attempted. Endoscopic mucosal resection (EMR) was successful and without adverse events with the combination of epinephrine, snare cautery, and clip placement to close the mucosal defect. Final pathology revealed a well-differentiated neuroendocrine tumor with low-grade and clear cautery margins.

One of the most common symptoms leading to detection of neuroendocrine tumors in the duodenum is upper GI bleeding. However, tumors at the ampulla of Vater can also present with jaundice. There are no standardized management protocols regarding early ampullary neuroendocrine tumors. EMR of neuroendocrine tumors > 1 cm have been shown to be successful in the duodenum though with limited data regarding long-term outcomes. Given the morbidity and mortality of pancreaticoduodenectomy, in patients with a low-grade neuroendocrine tumor < 2 cm, endoscopy should be considered.

EMR can be performed successfully on minimally invasive neuroendocrine tumors and remains an option for patients who either decline surgical intervention or are not favorable surgical candidates.

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